Sunrise application of the behavioral health coalition of southern Arizona

ARIZONA STATE SENATE
RESEARCH STAFF
TO: JOINT LEGISLATIVE AUDIT COMMITTEE HEATHER OWENS
Senator Robert Blendu, Chairman L E G I S L A T I V E RESEARCH ANALYST
HEALTH COMMITTEE
Representative John Nelson, Cochair Telephone. ( 602) 926- 3 17 I
DATE: December 3,2007
SUBJECT: Sunrise Application of the Behavioral Health Coalition of Southern Arizona
Attached is the final report of the sunrise review ofthe application submitted by the Behavioral
Health Coalition of Southern Arizona ( Coalition), which was conducted by the Senate Health and
House of Representatives Health Committee of Reference.
This report has been distributed to the following individuals and agencies:
Governor of the State of Arizona
The Honorable Janet Napolitano
President of the Senate
Senator Tim Bee
Speaker of the House of Representatives
Representative James Weiers
Senate Members House Members
Senator Tom O'Halleran, Cochairman Representative Bob Stump, Cochairman
Senator Barbara Leff Representative Nancy Barto
Senator Paula Aboud Representative Rick Murphy
Senator Thayer Verschoor Representative David Bradley
Senator Amanda Aguirre Representative Linda Lopez
Behavioral Health Coalition of Southern Arizona
Arizona State Library, Archives & Public Records
Office of the Auditor General
Senate Majority Staff
Senate Research Staff
Senate Minority Staff
Senate Resource Center
House Majority Staff
House Research Staff
House Minority Staff
Chief Clerk
HOfjas
Attachment
Senate Health and House of Repre~ entativesH ealth
Committee of Reference Report
SUNRISE REQUEST OF THE BEHAVIORAL HEALTH COALITION
OF SOUTHERN ARIZONA
Background
Pursuant to Arizona Revised Statutes ( A. R. S.) 5 32- 3 104, the Joint Legislative Audit Committee
( JLAC) assigned the sunrise review to the Senate Health and House of Representatives Health
Committee of Reference. Attached is a copy of the application submitted by the Coalition.
Conznzittee of Reference Sunset Review Procedures
The Committee of Reference held one public meeting on November 6, 2007, to review the
Coalition's sunrise application pursuant to A. R. S. tj 32- 3 104 and to hear public testimony.
Committee of Reference Recomnzendcrtions
The Committee of Reference recommends that the Legislature approve the sunrise application
submitted by the Coalition. However, the Committee of Reference did not approve a specific regulatory
board or procedures for regulating behavioral analysts.
Attcrcltments
I. Staff memo.
2. Sunrise request of the Behavioral Health Coalition of Southern Arizona.
3. Meeting notice.
4. An excerpt of the minutes of the Committee of Reference meeting relating to the sunrise
application.
ARIZONA STATE SENATE
RESEARCH STAFF
TO: MEMBERS OF TIHE HOUSE AND SENATE
HEALTH COMMITTEE OF REFERENCE
DATE: October 17,2007
HEATHER OWENS
ASSISTANT ANALYST
HEALTH COMMITTEE
Telephone: ( 602) 926- 3 17 1
Facs~ rnile:( 602) 926- 3833
SUBJECT: Sunrise Request of the Southern Arizona Behavioral Health Coalition
The following memo is background information regarding the request for regulation of Board
Certified Behavior Analysts. Also attached is a copy of the sunrise application submitted by the
Southern Arizona Behavioral Health Coalition ( Coalition). A public meeting is scheduled for
November 6,2007, to review, discuss and make a final recommendation as to the Coalition's request. If
you have any questions or need additional information, please feel free to contact me.
BACKGROUND
The field of applied behavior analysis ( ABA) is currently recognized and regulated by the
national Behavior Analysis Certification Board ( Board). The field of ABA is based on the scientific
research of experimental analysis of behavior. The California Department of Developmental Services
defines behavior analysis as " the design, implementation, and evaluation of instructional and
environmental modifications to produce socially significant improvements in human behavior through
skill acquisition and the reduction of problematic behavior."
Behavior analysts who meet the Board's education and experience requirements may voluntarily
receive Board certification by passing the Board's exam. A Board Certified Behavior Analyst ( BCBA)
typically receives formal training and experience in residential treatment settings, group care, family
homes, schools and job sites. According to the Coalition, the goal of a BCBA is to provide therapeutic
work in natural settings with treatment mediated by a professional and implemented through caregivers
such as family and teachers.
In Arizona, there are currently five professions licensed and authorized to provide behavioral
health services: 1) social workers; 2) marriage and family therapists; 3) licensed counselors; 4)
substance abuse counselors; and 5) licensed psychologists. A BCBA may not practice unless supervised
by a professional licensed in one of the five recognized behavioral health professions. According to the
Coalition, this adds redundancy and additional cost to the behavioral health system.
REQUEST FOR REGULATION
The Coalition requests the licensure of BCBAs by either the existing Arizona Board of
Behavioral Health Examiners or the Arizona Board of Psychologist Examiners.
The Coalition envisions licensure for BCRAs equivalent to other behavioral health professionals
or psychologists and suggests rearranging the membership of the chosen board to include at lcast onc
MEMORANDUM
October 17, 2007
Page 2
licensed BCBA. The licensing board would be able to conduct investigations on any complaints against
BCBAs and would have the power to renew, suspend or revoke licenses.
The Coalition recommends the Legislature require a licensed BCBA to be certified by the
national Board and adhere to the Board's training, supervision and experience standards. This includes
completion of 225 classroom hours of graduate level instruction in specific content areas, 1,500 hours of
supervised independent fieldwork and 36 hours of continuing education for certification renewal every
three years. The Coalition suggests that the chosen licensing board impose the same licensing fees on
BCBAs as other professions regulated by that board and adopt the current practice guidelines and code
of ethics the national Board uses for certification. The Coalition does not anticipate an increase in
expenses for the licensing board, because the licensing fees for BCBAs should cover the administration
costs.
According to the Coalition, there are approximately 30 BCBAs in Arizona. Northern Arizona
University currently offers an online graduate program for behavior analysis where graduates receive a
certificate in Positive Behavior Support ( PBS). The PBS certificate program is designed to prepare
students to meet the educational requirements of the Board and pass the BCBA exam. The Coalition
anticipates that allowing licensure of BCBAs in Arizona will cause the field to grow by attracting more
BCBAs to practice in the state.
OTHER STATES
The Massachusetts Legislature is currently considering legislation to allow licensure ofbehavior
analysts who have passed the BCBA and received certification from the national Board. If this bill
becomes law, the Massachusetts Board of Registration of Psychologists will issue licenses to qualified
HCBAs who apply. Florida, California, New York, Oklahoma, Pennsylvania and Texas previously
offered state certification and credentialing programs to behavior analysts, but no longer do so. Today
all credentialing of behavior analysts in these states is done by the national Board.
Attachment
P. O. Box 14261
Tucson, Arizona 85732
RECEIVED
Arizona Youth
Partnership
Arizona's Children
Association
Blake Foundation
Center Against Sex
Assault
Child & Family
Resources, Inc.
CODAC Behavior2
Health
Services
Compass Health C;
COPE Behavioral
Sew~ ces
Coyote Task Force
Esperero Famlly
Center
HOPE, lnc
lntermountaln Cent
Jew~ shF amlly and
Ch~ ldren's Svcs
La Frontera Center
La Paloma Fam~ ly
Services
Marana Health Cen
Our Famlly SCWICC
Pantano Behaworal
August 3 1,2007
The Honorable Robert Blendu
Sf? 9 4 2307
The Honorable John Nelson
Joint Legislative Audit Committee OFFICE OF THE PKtSlDENT
1700 west Washington
Phoenix, Arizona 85007
RE: Sunrise Report Relating to the Licensure of Board Certified Behavior Analysts to Allow
Practice in Arizona as a Behavioral Health Professional
Dear Senator Blendu and Representative Nelson:
On behalf of the Southern Arizona Behavioral Health Coalition, I have enclosed a Sunrise
Report to substantiate the need for licensure of Board Certified Behavior Analysts in
Arizona.
Briefly, the issue at hand is that while the profession of Board Certified Behavior Analysts,
with the training and experience requirements that are ideally designed for the behavioral
health issues and focus of the behavioral health system, is excluded from full practice as a
behavioral health professional. This profession has the training and experience that is
specifically oriented towards addressing the most significant issues in a person's hfe in the
context of the problem. The current system of licensure limits the availability of these trained
professionals to the consumer and exposes consumers to increased risk as persons less well
trained m this therapeut~ ca pproach are required to provide or supervise behavioral health
services. Furthermore, this lack of recognition of the profession of behavlor analyst adds
additional cost to the already burdened behavioral health system.
We look forward to worlang with you throughout the interim process. If you have any
questions or concerns, please do not hesitate to contact me.
Chairman
Southern Anzona Behavioral Health Coalition
Enclosure
. - d.
1 I
. .
SUNRISE REPORT
LICENSURE OF BOARD CERTIFIED BEHAVIOR
ANALYSTS
Proposed Statutory Change to Expand Licensure of Behavioral
Health Professionals or Licensed Psychologists to Include
Board Certified Behavior Analysts
Submitted by:
Southern Arizona Behavioral Health Coalition
Submitted August 31, 2007
The Issue: There are 5 groups of professionals authorized to provide,
supervise, and direct behavioral health services for individuals with
behavioral health issues: Social Workers, Marriage and Family Therapists,
Substance Abuse Counselors, Licensed Counselors, and Licensed
Psychologists. These professions are trained to assist individuals with
behavioral health issues via a variety of treatment approaches, one of
which might be techniques from the science of behavior analysis.
However, most of the training and experience for individuals in these
professions is based upon the methodology of traditional officelinsight
therapy. Most otherwise competent providers of behavioral health do not
hold expertise specific to the application of behavioral procedures. The
training and experience of behavior analysts are specifically oriented
towards addressing the most significant issues in a person's life within the
context where the problem occurs. This profession, with training and
experience requirements ideally suited for behavioral health issues, is
excluded from full practice as behavioral health professionals within the
behavioral health system in Arizona. This exclusion limits the availability to
consumers of trained professionals and exposes consumers to increased
risk. Furthermore, the current system takes on added redundancy and cost
when a qualified behavior analyst must be supervised by a licensed
behavioral health professional.
Executive Summary
The citizens of Arizona have the right to expect that the state will offer an
appropriate level of regulation for all health care services. The vast majority of
patients entering behavioral health treatment are vulnerable or impaired due to
their disorders. Behavioral health professionals serve some of the most
vulnerable of the state's residents, including children of all ages, adolescents, the
elderly, the seriously mentally ill, the chronically mentally ill and the
developmentally disabled.
Behavioral health services are typically provided to consumers in private, behind
the closed doors of their therapist's/ counselor's office. The consumers' lack of
sophistication regarding therapeutic protocol leaves them particularly vulnerable
to incompetent or unethical providers. Licensure of all behavioral health
professionals has ensured that these consumers receive at least the same level
of protection available to consumers of other health care services in Arizona;
however, the categories of licensed professionals also has prohibited access to
specially trained professionals ( behavior analysts). When assisting an individual
with behavior problems a thorough behavioral ( functional) assessment and a
well- designed and implemented behavioral intervention can mean the difference
between receiving effective treatment or languishing in care, or worse.
The Behavioral health system in Arizona has advanced towards the goal of
providing services according to the Arizona Vision: effective, strength based,
community based, individualized and driven by the family. A majority of services,
however, continue to occur through the out- patient clinic model. Services occur
during brief office visits, separated by a number of days ( usually no more than
once a week). When providing in- home services practitioners need to have more
than a passing familiarity with the skill- building strength- based model. The focus
must be on developing replacement behaviors that effectively and efficiently
alleviate problem situations. The system has implemented initiatives to move
further toward this model as evidenced by the Child and Family Team ( CFT)
initiative and the current Meet Me Where I Am project under implementation
across the state of Arizona. A best practice goal is therapeutic work in natural
settings with treatment mediated by a professional and ultimately implemented
through the caregivers ( e. g. teachers, parents) resulting in functional outcomes.
Perhaps not coincidentally, this is the model for interventions in the field of
Applied Behavior Analysis. This field is currently recognized and regulated via a
national organization, the Behavior Analysis Certification Board. Board Certified
Behavior Analysts ( BCBA) are mandated to provide empirical, best practice
interventions based on thorough behavioral assessments of problem situations,
that result in measurable progress. Yet BCBAs with this advanced training are
not able to provide services within the Arizona system unless supervised by a
professional, licensed in one of the 5 existing licensure categories, who likely
does not have an equivalent level of expertise.
Few behavioral health professionals have had more than brief, general training in
the application of behavioral techniques. Board Certified Behavior Analysts on
the other hand are required to have extensive coursework and experience in the
assessment of problem behaviors, and situations in which they occur, and in the
development and implementation of effective intervention plans. As a matter of
course these plans are implemented in the natural setting by the parents,
teachers, friends or other caregivers who are part of the person's life. Typical
settings in which behavior analysts receive formal training and supervised
experience prior to certification include residential treatment settings, group care,
family homes, schools and job sites. The addition of Board Certified Behavior
Analysts as professionals licensed by the Board of Behavioral Health or the
Board of Psychology will improve access to professionals trained to meet the
needs of the behavioral health consumer. This new licensure category will help
ensure that the goals of the behavioral health system are met, in a way that
ensures cost effective services and improved outcomes.
I. A Definition of the Problem and the Extent to Which Consumers Need
and Will Benefit from a Method of Regulation Identifying Competent
Practitioners of Applied Behavior Analysis:
Definition of the Problem.
There is a wide and growing range of issues for which people seek behavioral
health services. This list includes, but is not limited to, children and adults with
autism, developmental disabilities and co- occurring mental health disorders,
acute psychological distress, grief and loss, depression, suicide risk, child and
adult abuse, school and workplace violence, eating disorders, substance abuse,
aging issues and marriage or family distress and violence. Guided by the Arizona
Vision, the Division of Behavioral Health Services ( DBHS) strives to provide
accessible and timely services in collaboration with children, families and others,
tailored for the child and family with respect for individual cultural heritages, in
connection with natural supports with functional outcomes and best practices
promoting stability and independence. DBHS has developed and encouraged the
use of 26 best practice treatment approaches. Eighteen of these best practice
guidelines come from the field of Applied Behavior Analysis or include behavioral
techniques as a major component. Please refer to Attachment 1 for descriptions
of the DBHS best practice approaches.
Applied BehaviorAnalysis ( ABA) is a specialized area within the field of
psychology with the goal of utilizing the fundamental principles of human
behavior ( e. g., reinforcement, positive motivation, generalization and
maintenance) to help these populations strengthen or acquire new skills and use
these skills to effectively address the above issues and produce meaningful
change ( Baer, Wolf, & Risley, 1968 / 1987). The principles of ABA have been
applied successfully across many socially important behavioral areas of interest
or concern such as the treatment of autism. Attention- Deficit Hyperactivity
Disorder, Attachment Disorder, Conduct Disorder, Oppositional Defiance,
behavior problems, depression, alcohol and substance abuse, regular and
special education, pediatric medicine and sports psychology. Dr. Lovaas, the
developer of the most effective treatment approach for autism, and his co-authors
describes the foundation of treatment by behavior analysts in The Me
Book ( 1981). " Treatment should take place in the natural, everyday community,
with the locus being teaching done by the parents, teachers and other care
givers with emphasis on the development of functional skills to alleviate the
problem rather than diagnostic categories. Additional intervention is required
when treatment takes place more removed from the natural environment and is
done solely by ' professionals' as the effects or skills must then transfer to the
natural environment." Board Certified Behavior Analysts help all persons within
the client's natural environments to become " therapists" or " teachers." Behavior
analysts strive to ensure that these " natural therapists" have a working
knowledge of the processes and procedures studied and developed by behavior
analysts for providing effective help or instruction. This specialized approach
involves complex principles of human behavior and requires extensive study,
supervision and experience. However, the more thoroughly trained professionals
in this paradigm of best practice are not recognized as licensable in the Arizona
system.
Several academic and trade journals that represent specific medical disciplines
have published articles indicating that treatments derived from ABA- based
procedures for autism, developmental disabilities, depression, ADHD, and other
problem areas are empirically supported treatments. An article reviewing
literature on the assessment and treatment of individuals with mental retardation
and psychiatric disorders concluded that: " Interventions based on applied
behavior analysis have the strongest empirical basis, although there is some
evidence that other therapies have promise. " ( Sturmey, 2002). Also, Dr. Lilienfeld,
in a volume of the 2005 Pediatrics, the official journal of the American Academy
of Pediatrics, wrote an article offering guidelines on scientifically supported
treatments for childhood psychiatric disorders concluded: ' The most efficacious
psychosocial treatment for autism is applied behavior analysis. . .". Finally,
multiple legislative rulings have supported the efficacy of ABA- based approaches
for addressing both problem behaviors associated with developmental disabilities
and autism, as well as for educational instruction. Landmark decisions have been
made by the Federal District Court of Philadelphia, U. S. District Court for the
Northern District of Illinois, U. S. District Court for the Eastern District of
Michigan, South Carolina Federal District Court, U. S. District Court for the
Southern District of Indiana and the U. S. District Court for the Eastern
District of Tennessee; and when ruling on a case involving the use of ABA-based
treatment for children with autism the Supreme Court of British Colombia
concluded, ". . . It is beyond debate that the appropriate treatment is ABA or early
intensive behavioral intervention. "
The successful implementation of a best practice requires several elements.
First, the professional who assesses the problem, and designs and implements
the intervention must be well trained and experienced in the approach. Second,
the implementation of the intervention techniques must have the highest fidelity
to demonstrated best practice techniques. Variations, including omissions,
deviations or inclusion of unnecessary elements, are likely to significantly change
the nature of the interventions and result in less effective or potentially harmful
results. These less effective and harmful results affect the lives and well being of
the consumers of the services, result in continued problems for the individual,
longer durations of care within the behavioral health system, greater costs in
resources and support, and the erroneous determination by the consumer,
professional and system that a " best practice" approach is not effective.
The extent to which consumers need and will benefit from the regulation.
The Center for Disease Control ( CDC) reports that " Mental disorders are
common in the United States. One in two Americans could be diagnosed as
having a mental disorder each year, including 44 million adults and 13.7 million
children." The CDC concludes that " these disorders are as disabling as cancer or
heart disease in terms of premature death and lost productivity." It is further
reported that " of those with a diagnosable mental disorder . . . fewer than half of
the adults get help and only one third of children receive treatment." The CDC
identified 5 barriers to care, one of which was health care providers unaware of
effective treatments. ( www. cdc. qov obtained 8120107). A United States
Department of Health and Human Services Mental Health Report of the Surgeon
General in1 999 recommends that improving the system will require ensuring a
supply of mental health services and providers. The Surgeon General found key
personnel shortages in mental health professionals and " specialists with
expertise in cognitive- behavioral therapy . . . shown to be effective for several
severe mental disorders." If all one considers is the need for expert behavioral
interventions from the perspective of the children in Arizona suffering from autism
spectrum disorders the lack of qualified professionals in this discipline is
devastating. The latest estimate of prevalence of autism indicates that one in
every 150 children are diagnosed with an autism spectrum disorder. The CDC
reports that 3,574 children between the ages of 3- 21 years are classified as
having autism by the Arizona Department of Education in the year 2005- 06. That
number is .33% of the 1,904,226 children enrolled in Arizona public schools in
2005. With 6.2 per 1,000 children diagnosed with autism each year, it can be
anticipated that 280 additional children per year will be diagnosed with autism
spectrum disorder. Early, intensive intervention involving the implementation of
behavior analytic procedures to teach language, self care, compliance, social
skills and academic skills is the most effective treatment for this disorder;
however, the state of Arizona behavioral health system does not recognize or
license those professionals trained in the implementation of these techniques.
Therefore, parents must obtain treatment from professionals who do not have
specialized training, or search outside the behavioral health system for this
expertise.
Extent of autonomy of a practitioner.
As described by the Behavior Analysis Certification Board ( BACB), " the Board
Certified Behavior Analyst ( BCBA) is an independent practitioner who also may
work as an employee or independent contractor for an organization. The BACB
requires that the BCBA conduct descriptive and systematic ( e. g., analogue)
behavioral assessments, including functional analyses, and provides behavior
analytic interpretations of the results. The BCBA must design and supervise
behavior analytic interventions implemented by others. The BCBA effectively
develops and implements appropriate assessments and intervention methods for
use in unfamiliar situations and for a range of cases. The BCBA must seek the
consultation of more experienced practitioners when necessary. The BCBA
teaches others to carry out ethical and effective behavior analytic interventions
based on published research and designs and delivers instruction in behavior
analysis" ( www. BACB. com). The BACB strongly recommends that the Board
Certified Behavior Analyst supervise the work of Board Certified Associate
Behavior Analysts and others who implement behavior analytic interventions.
In Arizona the regulations guiding behavioral health have placed the system in
the untenable position of mandating a treatment orientation and modality
( evidence based practice, behavioral interventions and approaches) but not
supporting and recognizing a discipline uniquely designed to provide such
treatment. As a result, such services are unavailable to the behavioral health
consumer or are received from professionals who often have little training or
experience to provide such treatment.
2. The efforts made to address the problem include:
Voluntary efforts.
Given the vulnerability of consumers of behavioral health services, it is critically
important that they have access to professionals with the highest levels of
training and experience specific to the problems being addressed and that they
are protected from incompetent or unethical providers. The current level of
regulation of behavioral health professional is inadequate to provide an
appropriate level of protection to these consumers. Of the over 20,000 licensed
behavioral health providers, the experience and training in the area of behavior
analysis is generally limited to training that has been obtained post degree or
through limited coursework, usually optional, obtained while in school. Specific
training and experience in providing behavioral interventions is not required for
licensure. ( See Attachment 2 for a comparison of the training requirements for
behavioral health professionals and Board Certified Behavior Analysts).
However, behavioral interventions have been identified as best practices for
many issues including depression, ADHD, obsessive compulsive disorders,
autism, and most childrens' behavioral health disorders. Dr. Scott 0. Lilienfeld in
The Scientific Review of Mental Health Practice ( 2004,) notes that many or most
anxiety disorders and most childhood disorders respond better to behavioral and
cognitive behavioral therapies than to supportive therapies or other therapies that
do not rely on behavioral techniques. The lack of expertise in the application of
behavioral interventions among the available licensed professionals, and the
absence of licensure for Board Certified Behavior Analysts to practice or
supervise the clinical practice of services in behavioral health, puts the burden on
consumers to individually determine the competency of potential providers. This
puts an additional duty on consumers of behavioral health services not required
of consumers of other health services presently regulated by the state.
Acknowledging the certification of behavior analysts and including this profession
as a licensable profession would assure access to a wider variety of
professionals.
Establish a code of ethics, and recourse to use amendment to existing
applicable law.
The issue requires resolution via amendment of the applicable licensing laws
either by including the BCBA as a profession regulated by the board of
psychologists or the behavioral health board. The licensed behavior analyst
would be required to meet training, supervision and experience standards as
outlined by the BACB. ( See Attachment 3 for the BACB requirements). Requiring
adherence to these specific standards is one method that insures public safety in
the implementation of the powerful techniques of Applied Behavior Analysis. In
addition, requiring that behavior analysts licensed to practice under the proposed
new law are certified through the BACB would increase protection for the public
by requiring that licensed behavior analysts subscribe to the ethical and
professional guidelines of the BACB.
Board Certified Behavior Analysts are required to abide by a set of practice
guidelines and code of ethics, as are all of the licensed professionals currently
recognized in the state of Arizona. BCBA guidelines are comparable to the
guidelines of other professional organizations, including:
American Anthropological Association
American Educational Research Association
American Psychological Association
American Sociological Association
California Association for Behavior Analysis
Florida Association for Behavior Analysis
National Association of Social Workers
National Association of School Psychologists
Texas Association for Behavior Analysis
These Guidelines address ethical concerns particular to Board Certified Behavior
Analysts and Board Certified Associate Behavior Analysts, as well as concerns
that are salient to the relationship between certified professionals, the people
they serve, and society in general. In addition, the behavior analyst guidelines
include requirements tailored to the unique services and technical interventions
of a behavior analyst.
Specifically, the guidelines establish that a behavior analyst rely on scientific
principles and provide services, teach, and conduct research within the
boundaries of their competence, based on their education, training, supervised
experience, or relevant professional experience. Behavior analysts'
assessments, recommendations, reports, and evaluative statements are based
on information and techniques sufficient to provide appropriate substantiation of
their findings. A behavior analyst must conduct a functional assessment, as
defined in applied behavior analysis best practice literature, to provide the
necessary data to develop an effective behavior change program, and accept as
clients only those individuals or entities ( agencies, firms, etc.) whose behavior
problems, or requested services are commensurate with the behavior analyst's
education, training, and experience. A behavior analyst 1) designs programs that
are based on behavior analytic principles, 2) including assessments of the effects
of other intervention methods, 3) involves the client or the client- surrogate in the
planning of such programs, 4) obtains the consent of the client, and 5) respects
the right of the client to terminate services at any time. The behavior analyst
recommends reinforcement rather than punishment whenever possible. The
behavior analyst minimizes the use of potential reinforcers that may be harmful to
the long- term health of the client ( e. g., cigarettes, or sugar or fat- laden food), or
that may require undesirably marked deprivation procedures as establishing
operations. The behavior analyst collects data, or asks the client, client-surrogate,
or designated others to collect data needed to assess progress within
the program. The behavior analyst modifies the program on the basis of data.
The behavior analyst reviews and appraises the restrictiveness of alternative
interventions and always recommends the least restrictive procedures likely to be
effective in dealing with a behavior problem.
3. Alternatives including regulation of business employers or practitioners
rather than employee practitioners, regulation of the program or service
rather than the individual practitioners, registration of all practitioners and
certification of practitioners, and why the use of alternatives would not be
adequate to protect the public interest, why licensing would serve to
protect the public interest:
Typical employers and extent of autonomy of behavior analysts.
Behavior Analysts provide services to meet diverse behavioral needs. Examples
of these applications include: building the skills and achievements of children in
school settings; enhancing the development, abilities, and choices of children
and adults with different kinds of disabilities; and augmenting the performance
and satisfaction of employees in organizations and businesses. Behavior
Analysts work for both organizations of service providers and in an independent
capacity as consultants or private practitioners.
Because of its prominent applications on behalf of people at- risk and historical
concerns for the humane treatment of consumers, Applied Behavior Analysis has
been the focus of many state regulations. In the course of defining the practice of
behavior analysis and establishing certification for practitioners, some succinct
regulatory definitions of the discipline have been developed in Florida, California
and New York. Massachusetts is currently proposing legislation to license
behavior analysts under the same state law as psychologists. ( See Attachment 4
for the Massachusetts legislation).
The states of Florida, California, New York, Oklahoma, Pennsylvania, and Texas
previously had state certification and credentialing programs for the behavior
analysts, but have transferred all of their credentialing of behavior analysts to the
Behavior Analyst Certification Board.
As is true of other behavioral health professions, the clients of behavior analysts
are diverse socially, economically, culturally and ethnically. Behavior Analysts
help individuals of widely varying functional abilities in a variety of settings
including, predominantly, the settings in which the problem exits. These settings
include private homes, schools, licensed residential settings, private practices,
mental health centers, rehabilitation agencies, private nursing homes, licensed
health facilities, schools and businesses. In Arizona the regulated employers,
such as licensed behavioral health facilities, require licensure for employees
providing behavioral health counseling services, and are unable to recognize the
BCBA as a qualified professional unless helshe holds licensure under the board
of psychology or board of behavioral health. The risk of harm to the public
created by this restriction of practitioners is serious because behavioral health
services are generally provided by individuals one- on- one behind closed doors to
vulnerable patients. In these situations the public relies on the oversight of
supervisors to ensure that practice meets standards. If the supervisor is
unfamiliar with the specific procedures and techniques of behavior analysis,
effective supervision is not possible and the public risk is increased.
Dangers of misuse of techniques by less well trained people or
paraprofessionals under the direction of less well trained professionals.
Problems with the unethical and harmful application of " behavioral - like"
techniques prompted the Florida Legislature in the early 1970' s to form a blue
ribbon panel to study the issue. The recommendations of this blue ribbon panel
resulted in the development of the Florida certification of behavior analysts and
the legislative requirement that individuals developing and applying behavioral
procedures with developmentally delayed individuals become certified. This
process and its inherent protection is recognized as valuable for other
populations and the Board Certified Behavior Analyst has been in demand with
many services for other populations.
Licensed behavioral health professionals and psychologists are uniquely situated
to have an enormous impact on their patients. Appropriately trained and
regulated professionals provide invaluable assistance to help their patients
achieve the highest possible level of functioning and well- being. Untrained or
unregulated individuals, however, have the potential to inflict irreparable harm. If
the system were to provide for behavior analysts the requirements regarding
qualifications for licensure and oversight it could prevent misuse of procedures,
improve fidelity of interventions to the behavioral approach, increase positive
outcomes and reduce cost.
Given the vulnerability of consumers of behavioral health services, it is critical
that they be protected from incompetent or unethical providers. This petition
seeks licensure for Board Certified Behavior Analysts equivalent with behavioral
health professionals or psychologists to ensure that consumers of behavioral
health services receive the same level of protection provided to consumers of
other health care services. Individuals are allowed to practice if they could
demonstrate appropriate levels of education, experience and competence. The
licensing Board is able to provide informed investigations and take action on
complaints against all behavioral health providers.
Efforts made to address the problem.
Voluntary certification of behavior analysts has been instituted to help consumers
identify competent practitioners and to provide them with an avenue of redress
against incompetent or unprofessional practitioners. As previously decided by the
State of Arizona with the Board of Behavioral Health, voluntary certification of
practitioners fails to adequately protect the public. Consumers of behavioral
health services are among the most vulnerable and often the least sophisticated
of the state's residents. It is not reasonable to put the burden on patients to
understand the system and seek out providers and professionals sufficiently
trained and credentialed in behavioral principles and techniques.
The Behavior Analysis Certification Board is a national professional association
that regulates certified practitioners who must adhere to published codes of
ethics, and offers a review process for consumer complaints alleging ethical
violations by practitioners. While admirable, these review processes may be
inadequate to protect the public. First, a professional association offers voluntary
membership to professionals. The association has no authority to review
complaints against non- members. Second, even if a consumer complaint results
in discipline against a member, the association has no power to enforce the
discipline imposed. If a member fails to comply with a disciplinary decision by an
association, the association's only recourse is to eject the member from the
association. Finally, disciplinary reviews by professional associations are
conducted by other professionals in the discipline. The lack of public input into
these reviews compromises the fairness necessary for the public to be assured
that their interests are being adequately protected.
Alternatives considered - regulation of business employers or
practitioners.
The Department of Health Services ( DHS) licenses behavioral health facilities
receiving state funds. DHS requires behavioral health professionals working in
licensed facilities to be licensed or clinically supervised by license holders. A
large percentage of behavioral health practitioners in Arizona, however, do not
have expertise in behavior analysis, and while a Board Certified Behavior Analyst
might work for a licensed behavioral health facility, they may not provide clinical
supervision of others ( wherein the expertise of that professional might be
extended to others practicing for the agency). Currently a BCBA must be
supervised by a licensed professional who may not have gained the knowledge
and expertise to adequately provide the oversight for behavioral services.
Inclusion of the Board Certified Behavior Analyst as a licensed professional in the
State of Arizona would provide for supervision of behaviorally based services by
the appropriately trained professional, and provide the public with the protection
inherent in this system.
4. The benefits to the Public Achieved By Licensing Board Certified
Behavior Analysts include:
The benefits to the public achieved by licensing behavioral health professionals
are increased access to services and increased safety. First, recognition and
inclusion of Board Certified Behavior Analysts in the licensing regulation would
insure that the public would have access to professionals with specialization in
the application of behavioral procedures to promote positive behavior change.
Second, all behavioral health professionals providing behavior analysis services
in Arizona would be subject to the Board's jurisdiction or the jurisdiction of the
Board of Psychology. This oversight function would prevent incompetent and
unprofessional practitioners from providing services outside the scope of any
state regulation and would provide a forum for review of all consumer complaints
against behavioral health professionals. Also of importance, the licensure of
Board Certified Behavior Analysts would allow cost effective behavior analysis
services without redundant supervision from other ( less behaviorally skilled)
licensed behavioral health professionals.
The inclusion of Board Certified Behavior Analysts as licensed professionals
would ensure the public has access to relevant information for making informed
decisions with respect to choosing a professional treatment provider. Currently,
the public is largely unaware that such a specialization exists, or that many
otherwise competent providers of behavioral health do not hold expertise specific
to the application of behavioral procedures.
It is proposed for the licensure of Board Certified Behavior Analysts to be
subsumed under the Board of Behavioral Health or the Board of Psychology. The
designated board would be arranged to include at least one licensed BCBA so
that specific expertise could be represented when making oversight decisions.
The Board's workload and efficiency could be maximized by requiring that
applicants first become certified by the Behavior Analysis Certification Board
( BACB) before applying for licensure with the state of Arizona. The designated
Arizona Board would have the authority to revoke, suspend or not renew licenses
for cause. It would adopt the ethics and practice guidelines established by the
BACB and require adherence to these guidelines. In addition the board would
receive complaints and take disciplinary action against practitioners, and levy the
same fees as other disciplines regulated by the board.
No grandfather clause is proposed or necessary as this does not change or
affect the practice of currently licensed individuals.
It is proposed that the same reciprocity agreements with other jurisdictions are
applied for Board Certified Behavior Analysts who become licensed, as are in
place with other licensed practitioners. The BACB has established training and
supervision guidelines in line with the standards for other licensed behavioral
health providers including Social Work, Psychology and Counseling. Attachment
2 provides detailed information comparing the requirements for Board Certified
Behavior Analysts with other disciplines.
5. The extent to which regulation might harm the public and restrict entry
into the health profession, whether there are similar professions which
should be included or excluded:
The inclusion of Board Certified Behavior Analysts into the current licensure for
Behavioral Health Providers or Psychologists would not restrict access to
qualified providers. Inclusion would expand the available pool of providers to
include these additional, highly trained professionals. The standards proposed
are those currently in place for licensed providers and have not been deemed
unduly restrictive. As the BACB is the national entity governing the recognition
and practice of behavior analysis, the question of recognition and reciprocity of
professionals that migrate from other jurisdiction is simplified. Those BCBAs who
migrate to Arizona would be required to have the same qualifications as the
current Board Certified Behavior Analysts residing in Arizona. The Behavior
Analysis Certification Board certifies a level of behavior analyst below the BCBA
as an associate or assistant behavior analyst. This level requires a bachelor's
degree with specific course work and supervised experience, and minimum score
on a national examination. This level of training and experience corresponds
with the behavior health technician and should not be included in the proposed
legislation.
6. The maintenance of standards including: whether effective quality
assurance standards exist in the health profession and how the proposed
legislation will assure quality:
The existing quality assurance standards for licensed professions ( Behavior
Health Professionals and Psychologists) and the standards of the Behavior
Analysis Certification Board for the BCBA should be combined and applied to the
new category of licensed behavior analyst. The standards for the BCBA would
be strengthened through the inclusion in the licensing regulations. The current
code of ethics for Board Certified Behavior Analysts are practice guidelines, are
not written as enforcement codes, and do not have the strength of law behind
them. Including the BCBA under licensure will allow enforcement of the current
high standards for professional practices already enforced for Behavior Health
Professionals and Psychologists. Standards for suspension and revocation of
licensure that exist for currently licensed professions will be adopted for the new
category of BCBA.
7. A Description of the Groups proposed for regulation:
Currently there are approximately 30 Board Certified Behavior Analysts in the
state. It is estimated that the field will expand as Board Certified Behavior
Analysts are licensed, able to practice independently, and are valuable to
behavioral health service providers as Behavioral Health Professionals. States
that have promoted the recognition of behavior analysts such as Florida,
California and Massachusetts have over 600, over 350 and over 360 Board
Certified Behavior Analysts listed on the Behavior Analyst Certification Board,
respectively. Currently the University of Northern Arizona has a graduate
program to prepare students to become Board Certified Behavior Analysts and
these new practitioners will have an avenue to practice within the Arizona system
rather than migrating to other states that recognize the profession.
Licensure includes those individuals currently certified by the Behavior Analysis
Certification Board. There is no way to determine if non - registered BCBAs
reside in Arizona. Neither is there a way to determine if there are qualified
individuals residing in Arizona who are not certified.
8. Expected cost of regulation:
Both the Behavioral Health Examination Board and the Board of Psychology are
funded through the fees generated by licensing. The national Behavior Analysis
Certification Board is funded through the fees generated by examination and
certification of behavior analysts. It is not anticipated that the expenses will
increase with the addition of this category of professional, as the fees charged to
a BCBA applying for licensure will cover the cost of administering the program. It
is anticipated that the direct impact from licensure on the costs of behavioral
sewices for the state will be a decrease in the cost of services for individuals
sewed by licensed BCBAs. This cost reduction would result from the typical
behavior analytic service structure that provides training and support to the
persons directly involved with the clientlpatient including parents, teachers,
babysitters, etc. As the persons who are most involved with the client are trained
to teach, intervene, and respond using therapeutic techniques there is a
parametrically increased impact of the professional who provides more
therapeutic hours per dollar for the system.
For consumers who would directly pay for behavioral health professionals as
private pay clients, the recognition and regulation of an additional service
specialty may increase access to available services within the current cost
structure as the numbers of licensed behavior analysts and, therefore, licensed
professionals providing services increase. Requiring licensure for individuals
currently practicing without a license would increase their costs and this might be
passed on to the consumers.
Attachment 1
Descriptions of Best Practice Treatment Approaches Utilizing Applied Behavior Analysis
Techniques
There are 26 Best Practices identified by Arizona DBHS. These are:
Assertive Community Treatment *
Multi- systemic Therapy
= Functional Family Therapy
Dialectical Behavior Therapy
= Motivational Interviewing
Cognitive Behavioral Therapy
Supported Employment
= Wrap Around Service
Family Psychoeducation
= Supportive Housing - Therapeutic Foster Care *
= Relapse Prevention* - Family Systems *
= Solution Focused Brief Therapy *
= Community Reinforcement Approach
= Behavioral Marital Therapy
Motivational Enhancement Therapy - Social Skills Training*
= Naltrexone
- Opiate Replacement Therapies Behavior Contracting
Texas Medication Algorithm
Independent Hous~ ngw ith Supports . Brief Intervention for Alcohol AbuselDependence *
Multi- dimensional Family Therapy for Adolescents
= Emot~ onallyF ocused Therapy for Couples
At least 10 ( noted in bold) of these are best practices and are based on, incorporate or rely on
methods of applied behavior analysis. An additional 8 ( noted with an asterisk) often utilize
behav~ orm anagement ( procedures developed from the science of behavior analysis).
Descriptions retrieved 8124107 from the respective websites.
Multisytemic treatment or MST programs include coqnitive behavioral approaches, the behavior
therapies, behavioral parent training, pragmatic family therapies, and certain pharmacological
interventions that have a reasonable evidence base ( U. S. Department of Health and Human
Services [ DHHS], 1999). As these treatments are delivered in a considerably different context
than usual. For example, consistent with the view that the caregiver is key to achieving long- term
outcomes, a MST cognitive behavioral intervention would ideally be delivered by the caregiver
under the consultation of the ( behavior) therapist.
Functional Family Therapy ( FFT) clinicians develop and implement intermediate and, ultimately,
lonn- term behavior change plans that are culturally appropriate, context sensitive. and tailored to
the unique characteristics of each family member. The assessment focus in this phase includes
cognitive ( e. g., attributional processes and coping strategies), interactive ( e. g., reciprocity of
positive rather than negative behaviors, competent parenting, and understanding of behavior
sequences involved in delinquency), and emotional components ( e. g., blaming and negativity).
Clinicians provide concrete behavioral intervention to guide and model specific behavior changes
( e. g., parenting, communication, and conflict management). Particular emphasis is placed on
using Individualized and developmentally appropriate techniques that fit the family relational
system.
Community Reinforcement Approach
The Community Reinforcement Approach ( CRA) is a broad- spectrum behavioral
Proqram for treating substance abuse problems that has been empirically supported within
patients ( Azrin, 1976; Hunt & Azrin, 1973), outpatients ( Azrin, Sisson, Meyers, & Godley, 1982;
Mallams, Godley, Hall, & Meyers, 1982; Meyers & Miller, 2001). and homeless populations
( Smith, Meyers, & Delaney, 1998). In addition, three recent meta- analytic reviews cited it as one
of the most cost- effective alcohol treatment programs currently available ( Finney & Monahan,
1996; Holder, Longbaugh, Miller, & Rubonis, 1991; Miller etal., 1995). The first study to
demonstrate the effectiveness of CRA was conducted more than 25years ago ( Hunt & Azrin,
1973). ( It must be explained that Dr. Azrin is a founding practitioner of Applied Behavior Analysis,
and continues as a prominent leader in the field). References are available in the CRA manual.
Best practice guidelines promulgated by the Division of Health that require the use of
procedures based on Applied Behavior Analysis.
DBHS Best practice guidelines for disorders of attachment:
Through family centered approaches, primary caregivers should be taught how to nurture, how to
understand the reasons for their child's behaviors before disciplinary consequences are
considered, how to interact with children based on emotional, as well as chronological age, how
to be consistent and predictable, how to listen and talk with their children, how to develop and
maintain realistic expectations and how to teach and role model appropriate social behavior.
lnd~ viduatlr eatment of the child must be provided in the least restrictive, effective setting that
sustains proximity to home and natural supports. All service settings, a full array of covered
services, and specialty providers as indicated must be considered. The treatment continuum must
include community- based in- home services, respite, outpatient services and psychotropic
medication prescribing and monitoring. Counseling interventions can include individual, group
and play therapies that promote social skills, anger control, and behavioral channe and
Manaqement. It is understood that the majority of therapeutic interventions used for attachment
disordered children are taken from various therapeutic frameworks such as Psychodynamics,
Gestalt, Cognitive- Behavioral, Family Systems, Ericksonian, Object Relations, Attachment Theory
and Therapy.
DBHS Best practice guidelines for ADHD best practice protocol:
The focus of treatment should be on functional improvement such that the child/ adolescent will be
able to maintain behavior appropriate to hislher developmental level in multiple settings, including
home, school, work or social settings. Environmental Support should be provided to parent( s),
family members, teachers, and other members of the child's community. Each of these
individuals should be active members of the child's service plan. Each team member must have
an understanding of the child's condition, realistic behavioral expectations, and learned and
demonstrated successful behavior techniques, communication and parenting skills. The team
member will use these techniques and skills during and after termination of therapy in managing
ADHD at home, in school and in social situations. The home environment will be modified to
accommodate the clinical needs of the child. A thorough and comprehensive assessment of all
domains of a child's life must be made before a diagnosis is given. The core of the assessment
should be the parental interview, as the diagnosis rests primarily on observations of those closest
to the child and resulting clinical judgment. The child's behavior in home. school, and communitv
settings is evaluated with respect to the features of ADHD, and co- morbid conditions common to
this diagnosis are reviewed. Family functioning and its potential effect on symptoms are reviewed.
Information from the school, regarding the child's behavior and the appropriateness of the
learning environment, is obtained. The use of the Conners Scale or other behavioral rating scales
is particularly helpful in measuring baseline functioning and subsequent improvement.
Therapeutic strategies generally should utilize a broad- based range of interventions that may
include:
OPsycho- Educational approaches
OParent training in behavioral management skills
nclassroorn interventions
OCognitive behavioral therapy
OSocial skills training
Olndividual psychotherapy of the child
OFamily therapy
OLiving skills training
OHealth promotion with a focus on medication education and compliance and health- promoting
activities
OPeer and family support
ORespite
0 Other methods of intervention and treatment to address the specific identified needs of the
child and family.
All services provided should be consistent with the Arizona Principles and should rest, to the
extent possible, on community- based, natural supports, and respect for the child and family's
unique cultucal heritage and needs.
DBHS Best Practice Protocol for Services for individuals with Developmental Disabilities:
( Pertinent to the individuals in the DBHS system with DD)
Individual Counseling:
Cognitive- behavioral strategies may be used, with increased weight on the behavioral
component, for lower functioning individuals. Achievable and relevant goals and objectives
should be identified, and realistic expectations of progress established, as chaining and
generalization of goals may occur slowly.
Behavioral AssessmenVFunctionaI Analysis:
Challenging behaviors, like appropriate behaviors, are maintained by environmental, social and
physical reinforcers. The clinicians' task is to determine the function that the challenging
behaviors play in the individual's daily routine. This task is usually accomplished by conducting a
" Functional Analysis." A functional analysis includes an examination of the following:
flAntecedents and/ or consequences that affect or control a behavior;
OWhether the behavior represents a deficit or an excess, or is situationally appropriate;
UWhether different behavior patterns occur with different situations;
OPossible schedules of reinforcements that maintain the behavior;
OAn examination of environmental aspects and potential physical health issues that may
relate to the challenging behaviors; and
OPotential reinforcers and potential alternative behaviors that may be used in the
treatment plan to strengthen alternative behaviors.
Behaviors must be viewed in the situational and environmental context in which they occur and in
relation to the influences that manifest before, during and afler the behaviors. Antecedents may
provoke behaviors naturally ( like a loud noise causing an individual to jump) or through learning
( recognizing, over time, that self- injurious behavior lead to increased attention). Events following
a behavior can alter the likelihood of it recurring ~ f it is positively or negatively reinforced. Thus,
knowing antecedents and consequent events can be critical to understanding the reasons for
challenging behaviors and to developing therapeutic interventions.
Behavioral assessments must also explore the effects that challenging behaviors have on
caregivers, and who is most challenged by the behaviors. This allows service providers the
opportunity to support and promote the most effective caregiver responses and an opportunity not
only to change behaviors but also to shape and enhance the interpersonal environment in which
they occur.
In order to conduct a functional analysis the clinician will be required to interview family members,
other observers of the behaviors, and the individual as well as directly observe the individual
while helshe is engaged in target behaviors.
The results of the functional analysis lead directly to the formulation of a treatment intervention by
the CFT or ACT. Since interventions will need to occur throughout the day, family members.
teachers or other direct care staff must understand the rationale for the method, the exact
procedures to follow and the documentation that is required to measure the effectiveness of the
interventions.
Behavior Management:
The overall treatment strategy for behavioral interventions should emphasize the teaching of
social, communication and cognitive skills to the individual and effective behavior shaping
techniques to parents, to be used both during and afler termination of therapy. Applied Behavioral
Analysis Techniques and other behavioral management approaches should emphasize:
OThe development and encouragement of constructive and effectwe ways for individuals
to seek the attention they desire.
UPositive reinforcement for appropriate behavior and acknowledgment and reward of
the individual's ability to establish age- appropriate autonomy to the extent possible.
nldentification and minimization of the antecedents to behavioral disruptions, agitation or
self- injury by defining and utilizing positive or negative reinforcers.
OThe enhancement of the individual's repertoire of social and communicative behaviors
through social- pragmatic teaching.
OThe careful documentation in the service plan of desired outcomes and measurable
goals consistent with the individual's behavioral health needs.
Behavioral interventions must be coordinated with other agencies like DDD, which may be
providing similar interventions as part of habilitation. Habilitation services use a variety of
methods designed to maximize the person's abilities. Services typically are offered in the
person's home or community and include activities specific to learning to become more
independent.
Caregivers, family members and other providers in the individual's environment should be
actively engaged, including involvement with " homework" assignments. Strategies must be
integrated with other services and must be based on a thorough familiarity of the individual's
environment, routine, strengths and limitations and the assured cooperation of the individual's
caretakers, guardians, educators and other staff. As for all other service strategies,
signs/ symptoms of relapse or recurrence and exacerbating factors for co- occurring behavioral
health disorders should be identified and strategies developed for coping with exacerbating
factors.
Other governmental agencies promote the use of Applied Behavior Analysis as a best
practice.
The American Association on Mental Retardation, the oldest and largest interdisciplinary
organization of professionals concerned with mental retardation and related disabilities,
designated ABA- based procedures for the treatment of behavioral problems with individuals with
mental retardation and related disorders as " highly recommended" ( their highest rating). Based
on the scientific evidence supporting the efficacy of ABA- based procedures for treating problems
associated with mental retardation and autism, various scientific organizations have concluded
that ABA- based procedures are highly effective, including:
National institute of Mental Health
National Institute of Child Health and Human Development
rhtt- National Academies- Press (" Educating Children with Autism 12001)
Commission on Behavioral And Social Sciences and Education") )
American Association on Mental Retardation) (" Guidelines for the Treatment of
Psychiatric and Behavioral Problems in Mental Retardation"
American Psycholo~ icaAl ssociation ( Division 33; " Guidelines on Effective Behavioral
Treatment for Persons with Mental Retardation and Developmental Disabilities" )
Association for Science in the Treatment of Autism
Surgeon General of the United States 1999 report on mental health stated in reference to the
treatment of autism: " Thirfy years of research demonstrated the efficacy of applied behavioral
methods in reducing inappropriate behavior and in increasing communication, learning, and
appropriate social behavior. "
New York State Department sf Meaith (" Guidelines: Autism/ Pervasive Development
Disorders, Assessment and Intervention for Young Children ( 0- 3), Chapter IV -
Behavioral and Educational Approaches")
Caiifornia State Department of Developmental Services (" Autistic Spectrum
Disorders: Best Practice Guidelines for Screening, Diagnosis and Assessment")
Maine Administrators of Services far Ghifdren with Disabilities (" Report of the
MADSEC Autism Task Force")
-_ r^-- r.-, r *--, ., ..."- -..... -.. r,-. rr--. r-..... l-- ..,.-,. r.. ,. .^. Yt. .. a- _..
Attachment 2 - Requirements of Licenses for Arizona Compared with BCBA Certification Requirements
Licenses and
Certification
Requirements
BCBA
I Specific
( Board
Certified
Behavior
I
Analyst)
Psychologist
Education
Requirement
~ ehavior
Analysis
Training
Master's degree from an
institution of higher
education.
~ e ~ u i r e d
255 class room
Hours of Supervised
Independent
Fieldwork
hours in specific
core content areas
approved by the
Behavior Analyst
Certification Board
1500 hours of Supervised
Independent F~ eldwork~ n
behavlor analysis. The
d~ stnbution of Superwsed
Independent Fieldwork hours
must be at least 10 hours per
week, but not more than 30 hours I per week, for a minimum of 3 1 I I I I
Supervision Hours
25% telephonically, more
ocial Work Education.
~ nd~ v~ dtuhanl group
hours, 10 hours d~ rect
75 total hours and 5%
of total superv~ sed
hours, with at least
biweekly contact,
during
period
supervised work experience theories course
related field from an
accredited institution
including 48 hours in core
Exam
Required
LMFT
Ethics
Training
Required
YES YES
Sunrise application Definition o f Issue, Executive Summary and Question 1
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Attachment 3- Behavior Analysis Certification Board Requirements
Coursework: College or university courses in behavior analysis, that are taken from
an institution that meets the requirements specified.
The applicant must complete 225 classroom hours of graduate level instruction ( see
Acceptable Coursework below) in the following content areas and for the number of
hours specified :
a. Ethical considerations - 15 hours
b. Definition & characteristics and Principles, processes & concepts - 45 hours
c. Behavioral assessment and Selecting intervention outcomes & strategies - 35
hours
d. Experimental evaluation of interventions - 20 hours
e. Measurement of behavior and Displaying & interpreting behavioral data - 20
hours
f. Behavioral change procedures and Systems support 45 hours
g. Discretionary - 45 hours
Acceptable Coursework: Instruction of the type( s) specified in either a, b, or c,
below, will be accepted toward the coursework requirement.
Amount of Supervised Experience Required:
Supervised Independent Fieldwork: Applicants must complete 1500 hours of Supervised
Independent Fieldwork in behavior analysis. The distribution of Supervised Independent
Fieldwork hours must be at least 10 hours per week, but not more than 30 hours per week, for
a minimum of 3 weeks per month.
Amount of Supervision Required:
Supervised Independent Fieldwork: Applicants must be supervised at least once every 2
weeks for 5% of the total hours they spend in Supervised Independent Fieldwork. Total
supervision must be at least 75 hours. A supervisory period is two weeks.
1 Superv~ sed hours:
I I 5 ' 10
1 O/ O of total hours r_________- I___ I_-_ _ I___---- - - I - --
I
I
I
i Total number of
1 supervised hours 75
! ---.. -
Supervised Independent
Fieldwork
I Frequency of
I i 1 every 2 weeks
supervisor contacts
Total hours requ~ red ' T 1500 -
The applicant's primary focus should be on learning new behavior analytic skills related to the
BACB Third Edition Task List. Activities must adhere to the dimensions of applied behavior
analysis identified by Baer, Wolf, and Risley ( 1968) in the article Some Current Dimensions of
Applied Behavior Analysis published in the Journal of Applied Behavior Analysis. Applicants
are encouraged to have experiences in multiple sites and with multiple supervisors.
I :. . .
I . ,. a I
I i
i
I - Sunrise application Deiinition o f Issue, Executive Summary and Question 1
! - 8/ 30/ 2007
I I
! Appropriate experience activities include:
Conducting assessment activities related to the need for behavioral interventions,
Designing, implementing, and monitoring behavior analysis programs for clients,
Overseeing the implementation of behavior analysis programs by others,
Other activities normally performed by a behavior analyst that are directly related to behavior
analysis such as attending planning meetings regarding the behavior analysis program,
researching the literature related to the program, talking to individuals about the program; plus
any additional activities related to oversight of behavioral programming such as behavior analyst
supervision issues, or evaluation of behavior analysts' performance. The supervisor will determine
if activrties qualify.
Examples of activities that are not appropriate as experience activities include: attending
meetings with little or no behavior analytic content, providing interventions that are not based
in behavior analysis, doing non- behavior analytic administrative activities, or any other
activities that are not directly related to behavior analysis.
A. I n order to provide the public assurance that practitioners will maintain their
competence in the field it is proposed that the standards for continuing
education from the BACB be adopted as well as the requirements for
renewing licensure. The renewal would require proof of continuing education
and a fee. For BCBA recertification in the 3rd year of the certification cycle
requires the following:
1. For BCBA certificants, proof of completion of 36 hours of acceptable
continuing education as described in Section 11.
Type 1
Completion of graduate level college or university courses, for BCBAs, or
undergraduate or graduate, college or university courses, for BCABAs. Course
content must be entirely behavior analytic.
I
1 Type 2
Completion of events sponsored by providers approved by the Behavior Analyst
Certification Board. Any portion or all of the total required number of hours of
continuing education may be applied from this category during any three- year
certification period.
Type 3
Completion of a seminar, colloquium, presentation, conference event, workshop or
symposium not approved by the BACB, only i f they relate directly to the practice of
behavior analysis. A maximum of 25 percent of the total required number of hours of
continuing education may be applied from this category during any three- year
certification period.
TY pe 4
Instruction by the applicant of a category 1 or 2 continuing education events, on a
one- time basis for each event, provided that the applicant was present for the
complete event. A maximum of 25 percent of the total required number of hours of
Sunrise application Definition of Issue, Executive Summary and Question 1
8/ 3 0/ 2007
continuing education may come from this category during any three- year
certification period.
Type 5
Credentialing events or activities initiated and pre- approved for CEU by the BACB. A
maximum of 25 percent of the total required number of hours of continuing
education may come from this category during any three- year certification period.
Type 6
Passing, during the third year of the applicant's certification period, the BACB
certification examination appropriate to the type of certification being renewed.
Sunrise application Definition of Issue, Executive Summary and Question 1
8/ 30/ 2007
Attachment 4 Massachusetts Legislation for Licensure of Behavior
Analysts
H2244, SD2039 - An Act relative to behavior analysts
SECTION 1. Section 1 18 of chapter 1 12 of the General Laws, as appearing in the 2004
Official Edition, is hereby amended by inserting after the word " meanings" in line 3, the
following words:-
" Associate behavior analyst", an individual who by training and experience meets the
requirements of the national Behavior Analyst Certification BoardO and has passed the
examination and received certification as a Board Certified Associate Behavior Analyst 0.
" Behavior analysis", the design, implementation, and evaluation of instructional and
environmental modifications to produce socially significant improvements in human
behavior through skill acquisition and the reduction of problematic behavior. A behavior
analysis program shall be based on empirical research, include the direct observation and
measurement of behavior as well as a functional behavioral assessment; and utilize
antecedent stimuli, positive reinforcement and other consequences to produce behavior
change.
" Behavior analyst", an individual who by training and experience meets the requirements
of the national Behavior Analyst Certification Board O and has passed the examination
and received certification as a Board Certified Behavior Analyst 0 .
SECTION 2. Section 79 of chapter 13 of the General Laws, as appearing in the 2004
Official Edition, is hereby amended by inserting after the word " psychology", in line 10,
the following words:- " or behavior analysis".
SECTION 3. Chapter 112 of the General Laws, as appearing in the 2004 Official Edition,
is hereby amended by inserting after section 119 the following section:-
Section 1 19A. Each person desiring to obtain a license as an associate behavior analyst
shall make application to the board upon such form and in such manner as the board shall
prescribe and shall furnish evidence satisfactory to the board that such person:
( a) is of good moral character;
( b) has passed the examination and received certification as a Board Certified Associate
Behavior AnalystO;
( c) has maintained active status and has fulfilled all requirements for renewal and
recertification as a Board Certified Associate Behavior AnalystO; and
( d) conducts his professional activities in accordance with accepted standards such as the
Ethical Standards of Psychologists of the American Psychological Association and the
Guidelines for Responsible Conduct of the Behavior Analyst Certification BoardO.
Sunrise application Definition of Issue, Executive Summary and Question 1
8/ 30/ 2007
Each person desiring to obtain a license as a behavior analyst shall make application to the
board upon such form and in such manner as the board shall prescribe and shall furnish
evidence satisfactory to the board that such person:
( a) is of good moral character;
( b) has passed the examination and received certification as a Board Certified Behavior
AnalystO;
( c) has maintained active status and has fulfilled all r~ quirementsfo r renewal and
recertification as a Board Certified Associate Behavior Ana1yst. O; and
( d) conducts his professional activities in accordance with accepted standards such as the
Ethical Standards of Psychologists of the American Psychological Association and the
Guidelines for Responsible Conduct of the Behavior Analyst Certification BoardO.
SECTION 4. No person shall hold himself out to be an associate behavior analyst or a
behavior analyst unless he has met the applicable requirements set forth in section one
hundred and eighteen.
Violation of this section shall be punishable by a fine of not more than five hundred
dollars, or by imprisonment for not more than three months, or by the suspension or loss of
a license as a psychologist, or any combination thereof.
SECTION 5. Section 128 of chapter 112 of the General Laws, as appearing in the 2004
Official Edition, is hereby amended by striking out the first paragraph and inserting in
place thereof the following paragraph:-
The board shall investigate all complaints relating to the proper practice of behavior
analysis by any person licensed or certified as a behavior analyst or associate behavior
analyst under sections one hundred and eighteen to one hundred and twenty- nine A,
inclusive.
Sunrise application Definition of Issue, Executive Summary and Question 1
8/ 3 012007
References
Arizona Department of Health Services, ( 2005, April 1). Practice Improvement Protocol 11: Best
Practices. Retrieved August 20, 2007, from ADHS Division of Behavioral Health Services
Web site: http~// www. azdhs qovlbhslquidance/ bp. pdf
BACB. Inc., ( 2007, April). Revised Standards for Board Certified Behavior Analyst@ ( BCBAB).
Retrieved August 20, 2007, from Behavior Analyst Certification Board Web site:
http.// www. bacb. comlbecom frame. html
Baer, Don M., Wolf, Montrose M., & Risley, Todd R. ( 1968). Some Current Dimensions of Applied
Behavior Analysis. Journal of Applied Behavior Analysis, 1, 91 - 97.
Baer, Don M., Wolf, Montrose M., & Risley, Todd R. ( 1987). Some Still Current Dimensions of
Applied Behavior Analysis, Journal of Applied Behavior Analysis, 20, 31 3- 327.
Hagopian, Louis P. & Boelter, Eric W., ( 2005). Applied Behavioral Analysis: Overview and
Summary of Scientific Support. Retrieved August 20. 2007. from Kennedy Krieger Institute
Web site: http: l/ www. kennedvkr1eqer. orq1kki m1sc. isp? pid= 4761
Herbert, James D., Sharp, Ian R., & Gaudiano. Brandon A., ( 2002). Separating fact from fiction in
the etiology and treatment of autism: A scientific review of the evidence. The Scientific
Review of Mental Health Practice, l( 1). Retrieved August 20, 2007, from
http: llsrmhp. orq/ 0lOl lauttsm html
Lovaas, I. Ovar, ( 1981). The ME Book. Austin, TX: Pro- Ed Press.
Meyers, Robert J. & Squires, Daniel D., ( 2001, September). The community reinforcement
approach: A guideline developed for the behavioral health recovery management project.
Retrieved August 20, 2007, from Behaworal Health Recovery Management Web site:
http:// www bhrm orq/ qu~ deltnes/ CRAmanuai. pdf
Multisystemic Therapy Services, ( 1998). Multisystemic Therapy Treatment Model. Retrieved
August 20, 2007, from MST Services Web site:
http: l/ mstservices com/ texVtreatment. html# sum
Rice, Catherine ( 2000). Prevalence of Autism Spectrum Disorders --- Autism and Developmental
Disabilities Monitoring Network, Six Sites, United States, 2000. Retrieved August 20, 2007,
from Centers for Disease Control and Prevention Web site:
http:// cdc qovlmmwrlpreviewlmmwrhtml/ ss560l a1 htm
Satcher, David ( 1 999). Mental Health: A Report of the Surgeon General. A report presented at
the 92nd Annual NAACP Convention, New Orleans, Louisiana. Retrieved August 20, 2007,
from http:/ lwww. cdc. qovlomh/ AMHlfactsheetslmental. htm
Sexton, Thomas L. & Alexander, James F., ( 2000, December). Functional Family Therapy.
Juvenile Justice Bulletin, Retrieved August 20, 2007, from
http: llwww. ncirs. qov/ html/ oiidpliibu12000 12 4/ contents. htmI# acknowledqe
Interim agendas can be obtained via the Internet at http: llwww. azleg. state. az. usllnterimCommittees. asp
ARIZONA STATE SENATE
INTERIM MEETING NOTICE
OPEN TO THE PUBLIC
SENATE HEALTH AND HOUSE HEALTH COMMITTEE OF REFERENCE
Date: Tuesday, November 6, 2007
Time: 9: 30 A. M.
Place: SHR 1
AGENDA
1. Call to Order
2. Opening Remarks
3. Sunset Review of the Board of Homeopathic Medical Examiners
Presentation by Auditor General
Response by Board of Homeopathic Medical Examiners
Public Testimony
Discussion
Recommendations by the Committee of Reference
4. Sunset Review of the Regulatory Board of Physician Assistants
Presentation by Regulatory Board of Physician Assistants
Public Testimony
Discussion
Recommendations by the Committee of Reference
5. Sunset Review of the Board of Behavioral Health Examiners
Presentation by Board of Behavioral Health Examiners
Public Testimony
Discussion
Recommendations by the Committee of Reference
6. Sunset Review of the Acupuncture Board of Examiners
Presentation by Acupuncture Board of Examiners
Public Testimony
Discussion
Recommendations by the Committee of Reference
7. Sunset Review of the Board of Occupational Therapy Examiners
Presentation by Board of Occupational Therapy Examiners
Public Testimony
Discussion
Recommendations by the Committee of Reference
Page 1 of 2
8. Sunrise application of the Arizona Alliance of Non- Physician Surgical Assistants
Presentation by Arizona Alliance of Non- Physician Surgical Assistants
Public Testimony
Discussion
Recommendations by the Committee of Reference
9. Sunrise application of the Southern Arizona Behavioral Health Coalition
Presentation by Southern Arizona Behavioral Health Coalition
Public Testimony
Discussion
Recommendations by the Committee of Reference
10. Sunrise application of the Arizona Dental Association
Presentation by Arizona Dental Association
Public Testimony
Discussion
Recommendations by the Committee of Reference
1 1. Sunrise application of Radiology Practitioner Assistants
Presentation by Radiology Practitioner Assistants
Public Testimony
Discussion
Recommendations by the Committee of Reference
12. Adjourn
Members:
Senator Tom O'Halleran, Co- Chair Representative Bob Stump, Co- Chair
Senator Paula Aboud Representative Nancy Barto
Senator Amanda Aguirre Representative David Bradley
Senator Barbara Leff Representative Linda Lopez
Senator Thayer Verschoor Representative Rick Murphy
Persons with a disability may request a reasonable accommodation such as a sign language interpreter, by contacting the
Senate Secretary's Office: ( 602) 926- 4231 ( voice). Requests should be made as early as possible to allow time to arrange the accommodation
Page 2 of 2
ARIZONA STATE LEGISLATURE
Forty- eighth Legislature - First Regular Session
SENATE HEALTH AND HOUSE HEALTH
COMMITTEE OF REFERENCE
Minutes of Interim Meeting
Tuesday, November 6,2007
Senate Hearing Room 1 - 9: 30 a. m.
Chairman O'Halleran called the meeting to order at 9: 32 a. m. and attendance was noted by the
secretary.
Members Present
Senator l'om O'Halleran, Co- Chair Representative Bob Stump, Co- Chair
Senator Amanda Aguirre Representative Nancy Barto
Senator Barbara Leff Representative David Bradley
Senator Thayer Verschoor Representative Linda Lopez
Representative Rick Murphy
Members Absent
Senator Paula Aboud
Speakers I'resent
Kim I- Iildebrand, Periormance Audit Manager, Office of the Auditor General
Todd Rowe, Board of Homeopathic Medical Examiners
Christine Springer, Board of Homeopathic Medical Examiners
Jerry Weinsheink, representing himself
Marianne Cherney, representing herself
Neil Garfield, Association for Public Access to Medicine
Barney Nugent, representing himself
Linda Heming, CHOICE
Iris Bell, Doctor, Arizona Homeopathic and Integrative Medical Association
Cliff Heinrich, Doctor, representing himself
Kathleen Fry, Doctor, representing herself
Denise Nugent, representing herself
Lee Bakunin, Attorney, representing herself
Bruce Shelton, Doctor, Arizona Homeopathic and Integrative Medical Association
Amanya Jacobs, Director of Evolution of Self School of Homeopathy
Cindy Zukerman, representing herself
Shelly Malone, representing herself
Stan Klusky, representing himself
Gladys Conroy, representing herself
SENATE HEAL1' tl AND HOUSE HEALTH
COMMITTEE OF REFERENCE
November 6,2007
Joan Reynolds, Regulatory Board of Physician Assistants
Debra Rinaudo, Board of Behavioral Health Examiners
Stuart Goodman, Board of Behavioral Health Examincrs
Bev Hermon, BH Consulting
Richard Poppy, Therapeutic Practitioners Alliance of Arizona ( The Alliance)
Rachael Hopkins, representing herself
Ronald Anton, representing himself
Josephine Sbrocca, representing herself
Cedric Davis, Board of Behavioral Health Examiners
Della Estrada, Arizona Acupuncture Board of Examiners
Kathryn Babits, Arizona State Board of Occupational Therapy Examiners
Eugene Smith, Arizona Alliance of Non- Physician Surgical Assistants
Susie Cannata, Arizona Alliance of Non- Physician Surgical Assistants
Rory Hays, Arizona Nurses' Association
Scott Leckie, Radiology Practitioner Assistants
Jane Van Valkenburg, Certification Board for Radiology Practitioner Assistants ( CBRPA)
Mary Connell, M. D., representing herself
Christine Lung, American Society of Radiologic Technologists ( ASRT)
John Gray, Grand Canyon University
Joyce Geyser, Arizona Radiological Society
James Abraham, National Society of Radiology Practitioner Assistants
I- leather Owens, Senate I- lealth Analyst
Aubrey Godwin, Medical Iiadiologic Technology Board of Examiners ( MRTBE)
Teresa Rodgers, Behavioral Health Coalition of Southern Arizona
David Giles, Behavioral Health Coalition of Southern Arizona
Holly Baumann, Southwest Autis~ nR esearch and Resource Center
John MacDonald, Arizona Dental Association ( ADA)
Rick Murray, Arizona Dental Association
Anita Elliott, Arizona Dental Association
Nicole Laslavic, Arizona Statc Dental Hygienists' Association
Janet Midkiff, Arizona State Dental Hygienists' Association
Nicole Albo, Arizona Dental Assistants' Association
Alisa Feugate, Arizona Dental Hygienists' Association
OPENING REMARKS
Chairman O'Halleran welcomcd everyone and requested that the speakers keep their comments
as brief as possible, as the committee members are well- versed in the issues to be discussed
today.
SUNSET REVIEW OF THE BOARD OF HOMEOPAT ~ X A M I N E R S
Presentation by Auditor ~ e n y
~ i m # Performance Audit Manager, Office of the Auditor General, gave a
+ entation on their findings issued in August, 2007 ( Attachment 1). Shc described the history
SENATE HEALTH AND HOUSE HEALTH
COMMITTEE OF REFERENCE
2 November 6,2007
voluntary certification. Chairman O'Halleran stated that this is inde0ed for lic Recommendations by the Committee of Reference
Health Committee of
amend the statutes of the Medical
to allow licensure of Registered
SUNRISE APPLICATION OF THE SOUTHERN ARIZONA BEHAVIORAL HEALTH
COALITION
Presentation by Southern Arizona Behavioral Health Coalition
Teresa Rodgers, Behavioral Health Coalition of Southern Arizona, explained that this application
was submitted in order to ensure that local practitioners meet standards of practice and are
licensed. She explained that behavioral analysts use different methodologies and work with
patients with various diagnoses including developmental disabilities and autism. She stated that
certification began thirty years ago in Florida in mental institutions and has since developed
nationwide.
Dr. Rodgers proposes that licensure go forward as a separate entity using the national standards
of the Behavior Analysis Certification Board.
Representative Lopez asked if there is a training program in Arizona; Dr. Rodgers stated that
Northern Arizona University has a program with 40 students. Representative Lopez asked if
there is a real need for this profession; Dr. Rodgers replied that the profession is growing
nationwide but it is currently difficult to find enough certified behavior analysts to meet the
demand.
Public Testimony
David Giles, Behavioral Health Coalition of Southern Arizona, supports the application,
explaining the importance of treatment plans for cognitively impaired people and the
requirement that treatment plans be authorized by licensed practitioners. He stated that this
profession is the best to treat children with autism.
Senator Leff asked if people practicing now would no longer be able to practice if the Legislature
allows licensure; Mr. Giles replied in the negative, explaining that this would provide a way for
families to find a clinician. Representative Bradley stated that licensure will actually expand
opportunities.
Holly Baumann, Southwest Autism Research and Resource Center, stated her support for this
application, explaining that the current lack of oversight represents a significant healthcare risk
for some of Arizona's most vulnerable citizens.
SENA'I'E HEALTH AND HOUSE HEALTH
COMMITTEE OF REFERENCE
November 6,2007
Discussion
Chairman O'Halleran asked for clarification about the motion; Ms. Owens explained the
interaction with other Boards.
Ms. Renaudo explained that for her agency the concern is the small number of behavioral health
professionals eligible for licensure, and that it would be impossible to regulate it because it will
not be self- funding.
Representative Bradley stated that the number is stagnant because these professionals have no
place to go, and that with licensure people will be drawn to Arizona. Senator Leff stated her
agreement .
Recommendations by the Committee of Reference
Cochairman Stump moved that the Senate and House Health Committee of
Reference approve the sunrise application of the Southern Arizona Behavioral
Health Coalition. The motion carried by a voice vote.
SUNRISE APPLICATION OF THE ARIZONA DENTAL ASSOCIATION /
Presentation by Arizona Dental Association / John MacDonald, Arizona Dental Association ( ADA), to explain the sunrise
application concerning access to care. He issue, including the
community needs assessments that have with stakeholders
( Attachment 14).
Rick Murray, Arizona Dental program proposes the creation of a
position called the Comn~ unity designed to be an extender
of the dental office and to the general supervision of a dentist.
The goal is to help bring across Arizona.
explained that the primary role of a COHR will be as
and oral health promotion and prevention, as
sent to the dental office prior to being seen by
thc dentist. /
the intent is to hire people from within the community, who may then
in the dental profession.
Public estimon + ole Laslavic, Arizona State Dental Hygienists' Association, stated that her organization does
not support the position but will not oppose this sunrise application.
Senator Leff asked for clarification of that position.
SENATE HEALTH AND HOUSE HEALTH
COMMITTEE OF REFERENCE
15 November 6,2007
Janet Midkiff, Arizona State Dental Hygienists' Association, stated that they support the concept
of training community people to be dental health representatives, and that the definition of the
COHR does make sense to them. She stated concerns about the education, licensing, or
certification of the people who fill the COHR positions. She said that her organization would
like to work with the ADA and to be a part of the access to care issue.
Nicole Albo, Arizona Dental Assistants' Association, stated her support for the COHR program
provided that the positions will be filled by certified dental assistants with additional training
components. She stated that she has been working with the ADA to develop a curriculum for
expanded COHR training.
Representative Murphy asked if the committee could approve the concept but not specify the
details, letting the Legislative process do that. Mr. Murray stated that the supervision issue is the
biggest concern.
Alisa Feugate, Arizona Dental Hygienists' Association, stated that she supports the concept of
the COHR but is neutral on the application at this time due to concerns about supervision and
scope of practice.
Recommendations by the Committee of Reference
Cochairman Stump moved that the Senate and House Health Committee of
Reference recommend that the Legislature amend the statutes of the Arizona Board
of Dental Examiners to create a new certified professional, the Community Oral
Health Representative, to coordinate community- based oral health promotion and
provide specified dental care under the general supervision of a licensed dentist.
The motion carried by a voice vote.
Without objection, the meeting adjourned at 4: 15 p. m.
Jane Dooley, Committee Secretary
November 6,2007
( Original minutes, attachments and audio on file in the Office of the Chief Clerk; video archives
available at http:// www. azle~.~ ov/)
SENATE HEALTH AND HOUSE HEALTH
COMMITTEE OF REFERENCE
November 6.2007

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Copyright to this resource is held by the creating agency and is provided here for educational purposes only. It may not be downloaded, reproduced or distributed in any format without written permission of the creating agency. Any attempt to circumvent the access controls placed on this file is a violation of United States and international copyright laws, and is subject to criminal prosecution.

ARIZONA STATE SENATE
RESEARCH STAFF
TO: JOINT LEGISLATIVE AUDIT COMMITTEE HEATHER OWENS
Senator Robert Blendu, Chairman L E G I S L A T I V E RESEARCH ANALYST
HEALTH COMMITTEE
Representative John Nelson, Cochair Telephone. ( 602) 926- 3 17 I
DATE: December 3,2007
SUBJECT: Sunrise Application of the Behavioral Health Coalition of Southern Arizona
Attached is the final report of the sunrise review ofthe application submitted by the Behavioral
Health Coalition of Southern Arizona ( Coalition), which was conducted by the Senate Health and
House of Representatives Health Committee of Reference.
This report has been distributed to the following individuals and agencies:
Governor of the State of Arizona
The Honorable Janet Napolitano
President of the Senate
Senator Tim Bee
Speaker of the House of Representatives
Representative James Weiers
Senate Members House Members
Senator Tom O'Halleran, Cochairman Representative Bob Stump, Cochairman
Senator Barbara Leff Representative Nancy Barto
Senator Paula Aboud Representative Rick Murphy
Senator Thayer Verschoor Representative David Bradley
Senator Amanda Aguirre Representative Linda Lopez
Behavioral Health Coalition of Southern Arizona
Arizona State Library, Archives & Public Records
Office of the Auditor General
Senate Majority Staff
Senate Research Staff
Senate Minority Staff
Senate Resource Center
House Majority Staff
House Research Staff
House Minority Staff
Chief Clerk
HOfjas
Attachment
Senate Health and House of Repre~ entativesH ealth
Committee of Reference Report
SUNRISE REQUEST OF THE BEHAVIORAL HEALTH COALITION
OF SOUTHERN ARIZONA
Background
Pursuant to Arizona Revised Statutes ( A. R. S.) 5 32- 3 104, the Joint Legislative Audit Committee
( JLAC) assigned the sunrise review to the Senate Health and House of Representatives Health
Committee of Reference. Attached is a copy of the application submitted by the Coalition.
Conznzittee of Reference Sunset Review Procedures
The Committee of Reference held one public meeting on November 6, 2007, to review the
Coalition's sunrise application pursuant to A. R. S. tj 32- 3 104 and to hear public testimony.
Committee of Reference Recomnzendcrtions
The Committee of Reference recommends that the Legislature approve the sunrise application
submitted by the Coalition. However, the Committee of Reference did not approve a specific regulatory
board or procedures for regulating behavioral analysts.
Attcrcltments
I. Staff memo.
2. Sunrise request of the Behavioral Health Coalition of Southern Arizona.
3. Meeting notice.
4. An excerpt of the minutes of the Committee of Reference meeting relating to the sunrise
application.
ARIZONA STATE SENATE
RESEARCH STAFF
TO: MEMBERS OF TIHE HOUSE AND SENATE
HEALTH COMMITTEE OF REFERENCE
DATE: October 17,2007
HEATHER OWENS
ASSISTANT ANALYST
HEALTH COMMITTEE
Telephone: ( 602) 926- 3 17 1
Facs~ rnile:( 602) 926- 3833
SUBJECT: Sunrise Request of the Southern Arizona Behavioral Health Coalition
The following memo is background information regarding the request for regulation of Board
Certified Behavior Analysts. Also attached is a copy of the sunrise application submitted by the
Southern Arizona Behavioral Health Coalition ( Coalition). A public meeting is scheduled for
November 6,2007, to review, discuss and make a final recommendation as to the Coalition's request. If
you have any questions or need additional information, please feel free to contact me.
BACKGROUND
The field of applied behavior analysis ( ABA) is currently recognized and regulated by the
national Behavior Analysis Certification Board ( Board). The field of ABA is based on the scientific
research of experimental analysis of behavior. The California Department of Developmental Services
defines behavior analysis as " the design, implementation, and evaluation of instructional and
environmental modifications to produce socially significant improvements in human behavior through
skill acquisition and the reduction of problematic behavior."
Behavior analysts who meet the Board's education and experience requirements may voluntarily
receive Board certification by passing the Board's exam. A Board Certified Behavior Analyst ( BCBA)
typically receives formal training and experience in residential treatment settings, group care, family
homes, schools and job sites. According to the Coalition, the goal of a BCBA is to provide therapeutic
work in natural settings with treatment mediated by a professional and implemented through caregivers
such as family and teachers.
In Arizona, there are currently five professions licensed and authorized to provide behavioral
health services: 1) social workers; 2) marriage and family therapists; 3) licensed counselors; 4)
substance abuse counselors; and 5) licensed psychologists. A BCBA may not practice unless supervised
by a professional licensed in one of the five recognized behavioral health professions. According to the
Coalition, this adds redundancy and additional cost to the behavioral health system.
REQUEST FOR REGULATION
The Coalition requests the licensure of BCBAs by either the existing Arizona Board of
Behavioral Health Examiners or the Arizona Board of Psychologist Examiners.
The Coalition envisions licensure for BCRAs equivalent to other behavioral health professionals
or psychologists and suggests rearranging the membership of the chosen board to include at lcast onc
MEMORANDUM
October 17, 2007
Page 2
licensed BCBA. The licensing board would be able to conduct investigations on any complaints against
BCBAs and would have the power to renew, suspend or revoke licenses.
The Coalition recommends the Legislature require a licensed BCBA to be certified by the
national Board and adhere to the Board's training, supervision and experience standards. This includes
completion of 225 classroom hours of graduate level instruction in specific content areas, 1,500 hours of
supervised independent fieldwork and 36 hours of continuing education for certification renewal every
three years. The Coalition suggests that the chosen licensing board impose the same licensing fees on
BCBAs as other professions regulated by that board and adopt the current practice guidelines and code
of ethics the national Board uses for certification. The Coalition does not anticipate an increase in
expenses for the licensing board, because the licensing fees for BCBAs should cover the administration
costs.
According to the Coalition, there are approximately 30 BCBAs in Arizona. Northern Arizona
University currently offers an online graduate program for behavior analysis where graduates receive a
certificate in Positive Behavior Support ( PBS). The PBS certificate program is designed to prepare
students to meet the educational requirements of the Board and pass the BCBA exam. The Coalition
anticipates that allowing licensure of BCBAs in Arizona will cause the field to grow by attracting more
BCBAs to practice in the state.
OTHER STATES
The Massachusetts Legislature is currently considering legislation to allow licensure ofbehavior
analysts who have passed the BCBA and received certification from the national Board. If this bill
becomes law, the Massachusetts Board of Registration of Psychologists will issue licenses to qualified
HCBAs who apply. Florida, California, New York, Oklahoma, Pennsylvania and Texas previously
offered state certification and credentialing programs to behavior analysts, but no longer do so. Today
all credentialing of behavior analysts in these states is done by the national Board.
Attachment
P. O. Box 14261
Tucson, Arizona 85732
RECEIVED
Arizona Youth
Partnership
Arizona's Children
Association
Blake Foundation
Center Against Sex
Assault
Child & Family
Resources, Inc.
CODAC Behavior2
Health
Services
Compass Health C;
COPE Behavioral
Sew~ ces
Coyote Task Force
Esperero Famlly
Center
HOPE, lnc
lntermountaln Cent
Jew~ shF amlly and
Ch~ ldren's Svcs
La Frontera Center
La Paloma Fam~ ly
Services
Marana Health Cen
Our Famlly SCWICC
Pantano Behaworal
August 3 1,2007
The Honorable Robert Blendu
Sf? 9 4 2307
The Honorable John Nelson
Joint Legislative Audit Committee OFFICE OF THE PKtSlDENT
1700 west Washington
Phoenix, Arizona 85007
RE: Sunrise Report Relating to the Licensure of Board Certified Behavior Analysts to Allow
Practice in Arizona as a Behavioral Health Professional
Dear Senator Blendu and Representative Nelson:
On behalf of the Southern Arizona Behavioral Health Coalition, I have enclosed a Sunrise
Report to substantiate the need for licensure of Board Certified Behavior Analysts in
Arizona.
Briefly, the issue at hand is that while the profession of Board Certified Behavior Analysts,
with the training and experience requirements that are ideally designed for the behavioral
health issues and focus of the behavioral health system, is excluded from full practice as a
behavioral health professional. This profession has the training and experience that is
specifically oriented towards addressing the most significant issues in a person's hfe in the
context of the problem. The current system of licensure limits the availability of these trained
professionals to the consumer and exposes consumers to increased risk as persons less well
trained m this therapeut~ ca pproach are required to provide or supervise behavioral health
services. Furthermore, this lack of recognition of the profession of behavlor analyst adds
additional cost to the already burdened behavioral health system.
We look forward to worlang with you throughout the interim process. If you have any
questions or concerns, please do not hesitate to contact me.
Chairman
Southern Anzona Behavioral Health Coalition
Enclosure
. - d.
1 I
. .
SUNRISE REPORT
LICENSURE OF BOARD CERTIFIED BEHAVIOR
ANALYSTS
Proposed Statutory Change to Expand Licensure of Behavioral
Health Professionals or Licensed Psychologists to Include
Board Certified Behavior Analysts
Submitted by:
Southern Arizona Behavioral Health Coalition
Submitted August 31, 2007
The Issue: There are 5 groups of professionals authorized to provide,
supervise, and direct behavioral health services for individuals with
behavioral health issues: Social Workers, Marriage and Family Therapists,
Substance Abuse Counselors, Licensed Counselors, and Licensed
Psychologists. These professions are trained to assist individuals with
behavioral health issues via a variety of treatment approaches, one of
which might be techniques from the science of behavior analysis.
However, most of the training and experience for individuals in these
professions is based upon the methodology of traditional officelinsight
therapy. Most otherwise competent providers of behavioral health do not
hold expertise specific to the application of behavioral procedures. The
training and experience of behavior analysts are specifically oriented
towards addressing the most significant issues in a person's life within the
context where the problem occurs. This profession, with training and
experience requirements ideally suited for behavioral health issues, is
excluded from full practice as behavioral health professionals within the
behavioral health system in Arizona. This exclusion limits the availability to
consumers of trained professionals and exposes consumers to increased
risk. Furthermore, the current system takes on added redundancy and cost
when a qualified behavior analyst must be supervised by a licensed
behavioral health professional.
Executive Summary
The citizens of Arizona have the right to expect that the state will offer an
appropriate level of regulation for all health care services. The vast majority of
patients entering behavioral health treatment are vulnerable or impaired due to
their disorders. Behavioral health professionals serve some of the most
vulnerable of the state's residents, including children of all ages, adolescents, the
elderly, the seriously mentally ill, the chronically mentally ill and the
developmentally disabled.
Behavioral health services are typically provided to consumers in private, behind
the closed doors of their therapist's/ counselor's office. The consumers' lack of
sophistication regarding therapeutic protocol leaves them particularly vulnerable
to incompetent or unethical providers. Licensure of all behavioral health
professionals has ensured that these consumers receive at least the same level
of protection available to consumers of other health care services in Arizona;
however, the categories of licensed professionals also has prohibited access to
specially trained professionals ( behavior analysts). When assisting an individual
with behavior problems a thorough behavioral ( functional) assessment and a
well- designed and implemented behavioral intervention can mean the difference
between receiving effective treatment or languishing in care, or worse.
The Behavioral health system in Arizona has advanced towards the goal of
providing services according to the Arizona Vision: effective, strength based,
community based, individualized and driven by the family. A majority of services,
however, continue to occur through the out- patient clinic model. Services occur
during brief office visits, separated by a number of days ( usually no more than
once a week). When providing in- home services practitioners need to have more
than a passing familiarity with the skill- building strength- based model. The focus
must be on developing replacement behaviors that effectively and efficiently
alleviate problem situations. The system has implemented initiatives to move
further toward this model as evidenced by the Child and Family Team ( CFT)
initiative and the current Meet Me Where I Am project under implementation
across the state of Arizona. A best practice goal is therapeutic work in natural
settings with treatment mediated by a professional and ultimately implemented
through the caregivers ( e. g. teachers, parents) resulting in functional outcomes.
Perhaps not coincidentally, this is the model for interventions in the field of
Applied Behavior Analysis. This field is currently recognized and regulated via a
national organization, the Behavior Analysis Certification Board. Board Certified
Behavior Analysts ( BCBA) are mandated to provide empirical, best practice
interventions based on thorough behavioral assessments of problem situations,
that result in measurable progress. Yet BCBAs with this advanced training are
not able to provide services within the Arizona system unless supervised by a
professional, licensed in one of the 5 existing licensure categories, who likely
does not have an equivalent level of expertise.
Few behavioral health professionals have had more than brief, general training in
the application of behavioral techniques. Board Certified Behavior Analysts on
the other hand are required to have extensive coursework and experience in the
assessment of problem behaviors, and situations in which they occur, and in the
development and implementation of effective intervention plans. As a matter of
course these plans are implemented in the natural setting by the parents,
teachers, friends or other caregivers who are part of the person's life. Typical
settings in which behavior analysts receive formal training and supervised
experience prior to certification include residential treatment settings, group care,
family homes, schools and job sites. The addition of Board Certified Behavior
Analysts as professionals licensed by the Board of Behavioral Health or the
Board of Psychology will improve access to professionals trained to meet the
needs of the behavioral health consumer. This new licensure category will help
ensure that the goals of the behavioral health system are met, in a way that
ensures cost effective services and improved outcomes.
I. A Definition of the Problem and the Extent to Which Consumers Need
and Will Benefit from a Method of Regulation Identifying Competent
Practitioners of Applied Behavior Analysis:
Definition of the Problem.
There is a wide and growing range of issues for which people seek behavioral
health services. This list includes, but is not limited to, children and adults with
autism, developmental disabilities and co- occurring mental health disorders,
acute psychological distress, grief and loss, depression, suicide risk, child and
adult abuse, school and workplace violence, eating disorders, substance abuse,
aging issues and marriage or family distress and violence. Guided by the Arizona
Vision, the Division of Behavioral Health Services ( DBHS) strives to provide
accessible and timely services in collaboration with children, families and others,
tailored for the child and family with respect for individual cultural heritages, in
connection with natural supports with functional outcomes and best practices
promoting stability and independence. DBHS has developed and encouraged the
use of 26 best practice treatment approaches. Eighteen of these best practice
guidelines come from the field of Applied Behavior Analysis or include behavioral
techniques as a major component. Please refer to Attachment 1 for descriptions
of the DBHS best practice approaches.
Applied BehaviorAnalysis ( ABA) is a specialized area within the field of
psychology with the goal of utilizing the fundamental principles of human
behavior ( e. g., reinforcement, positive motivation, generalization and
maintenance) to help these populations strengthen or acquire new skills and use
these skills to effectively address the above issues and produce meaningful
change ( Baer, Wolf, & Risley, 1968 / 1987). The principles of ABA have been
applied successfully across many socially important behavioral areas of interest
or concern such as the treatment of autism. Attention- Deficit Hyperactivity
Disorder, Attachment Disorder, Conduct Disorder, Oppositional Defiance,
behavior problems, depression, alcohol and substance abuse, regular and
special education, pediatric medicine and sports psychology. Dr. Lovaas, the
developer of the most effective treatment approach for autism, and his co-authors
describes the foundation of treatment by behavior analysts in The Me
Book ( 1981). " Treatment should take place in the natural, everyday community,
with the locus being teaching done by the parents, teachers and other care
givers with emphasis on the development of functional skills to alleviate the
problem rather than diagnostic categories. Additional intervention is required
when treatment takes place more removed from the natural environment and is
done solely by ' professionals' as the effects or skills must then transfer to the
natural environment." Board Certified Behavior Analysts help all persons within
the client's natural environments to become " therapists" or " teachers." Behavior
analysts strive to ensure that these " natural therapists" have a working
knowledge of the processes and procedures studied and developed by behavior
analysts for providing effective help or instruction. This specialized approach
involves complex principles of human behavior and requires extensive study,
supervision and experience. However, the more thoroughly trained professionals
in this paradigm of best practice are not recognized as licensable in the Arizona
system.
Several academic and trade journals that represent specific medical disciplines
have published articles indicating that treatments derived from ABA- based
procedures for autism, developmental disabilities, depression, ADHD, and other
problem areas are empirically supported treatments. An article reviewing
literature on the assessment and treatment of individuals with mental retardation
and psychiatric disorders concluded that: " Interventions based on applied
behavior analysis have the strongest empirical basis, although there is some
evidence that other therapies have promise. " ( Sturmey, 2002). Also, Dr. Lilienfeld,
in a volume of the 2005 Pediatrics, the official journal of the American Academy
of Pediatrics, wrote an article offering guidelines on scientifically supported
treatments for childhood psychiatric disorders concluded: ' The most efficacious
psychosocial treatment for autism is applied behavior analysis. . .". Finally,
multiple legislative rulings have supported the efficacy of ABA- based approaches
for addressing both problem behaviors associated with developmental disabilities
and autism, as well as for educational instruction. Landmark decisions have been
made by the Federal District Court of Philadelphia, U. S. District Court for the
Northern District of Illinois, U. S. District Court for the Eastern District of
Michigan, South Carolina Federal District Court, U. S. District Court for the
Southern District of Indiana and the U. S. District Court for the Eastern
District of Tennessee; and when ruling on a case involving the use of ABA-based
treatment for children with autism the Supreme Court of British Colombia
concluded, ". . . It is beyond debate that the appropriate treatment is ABA or early
intensive behavioral intervention. "
The successful implementation of a best practice requires several elements.
First, the professional who assesses the problem, and designs and implements
the intervention must be well trained and experienced in the approach. Second,
the implementation of the intervention techniques must have the highest fidelity
to demonstrated best practice techniques. Variations, including omissions,
deviations or inclusion of unnecessary elements, are likely to significantly change
the nature of the interventions and result in less effective or potentially harmful
results. These less effective and harmful results affect the lives and well being of
the consumers of the services, result in continued problems for the individual,
longer durations of care within the behavioral health system, greater costs in
resources and support, and the erroneous determination by the consumer,
professional and system that a " best practice" approach is not effective.
The extent to which consumers need and will benefit from the regulation.
The Center for Disease Control ( CDC) reports that " Mental disorders are
common in the United States. One in two Americans could be diagnosed as
having a mental disorder each year, including 44 million adults and 13.7 million
children." The CDC concludes that " these disorders are as disabling as cancer or
heart disease in terms of premature death and lost productivity." It is further
reported that " of those with a diagnosable mental disorder . . . fewer than half of
the adults get help and only one third of children receive treatment." The CDC
identified 5 barriers to care, one of which was health care providers unaware of
effective treatments. ( www. cdc. qov obtained 8120107). A United States
Department of Health and Human Services Mental Health Report of the Surgeon
General in1 999 recommends that improving the system will require ensuring a
supply of mental health services and providers. The Surgeon General found key
personnel shortages in mental health professionals and " specialists with
expertise in cognitive- behavioral therapy . . . shown to be effective for several
severe mental disorders." If all one considers is the need for expert behavioral
interventions from the perspective of the children in Arizona suffering from autism
spectrum disorders the lack of qualified professionals in this discipline is
devastating. The latest estimate of prevalence of autism indicates that one in
every 150 children are diagnosed with an autism spectrum disorder. The CDC
reports that 3,574 children between the ages of 3- 21 years are classified as
having autism by the Arizona Department of Education in the year 2005- 06. That
number is .33% of the 1,904,226 children enrolled in Arizona public schools in
2005. With 6.2 per 1,000 children diagnosed with autism each year, it can be
anticipated that 280 additional children per year will be diagnosed with autism
spectrum disorder. Early, intensive intervention involving the implementation of
behavior analytic procedures to teach language, self care, compliance, social
skills and academic skills is the most effective treatment for this disorder;
however, the state of Arizona behavioral health system does not recognize or
license those professionals trained in the implementation of these techniques.
Therefore, parents must obtain treatment from professionals who do not have
specialized training, or search outside the behavioral health system for this
expertise.
Extent of autonomy of a practitioner.
As described by the Behavior Analysis Certification Board ( BACB), " the Board
Certified Behavior Analyst ( BCBA) is an independent practitioner who also may
work as an employee or independent contractor for an organization. The BACB
requires that the BCBA conduct descriptive and systematic ( e. g., analogue)
behavioral assessments, including functional analyses, and provides behavior
analytic interpretations of the results. The BCBA must design and supervise
behavior analytic interventions implemented by others. The BCBA effectively
develops and implements appropriate assessments and intervention methods for
use in unfamiliar situations and for a range of cases. The BCBA must seek the
consultation of more experienced practitioners when necessary. The BCBA
teaches others to carry out ethical and effective behavior analytic interventions
based on published research and designs and delivers instruction in behavior
analysis" ( www. BACB. com). The BACB strongly recommends that the Board
Certified Behavior Analyst supervise the work of Board Certified Associate
Behavior Analysts and others who implement behavior analytic interventions.
In Arizona the regulations guiding behavioral health have placed the system in
the untenable position of mandating a treatment orientation and modality
( evidence based practice, behavioral interventions and approaches) but not
supporting and recognizing a discipline uniquely designed to provide such
treatment. As a result, such services are unavailable to the behavioral health
consumer or are received from professionals who often have little training or
experience to provide such treatment.
2. The efforts made to address the problem include:
Voluntary efforts.
Given the vulnerability of consumers of behavioral health services, it is critically
important that they have access to professionals with the highest levels of
training and experience specific to the problems being addressed and that they
are protected from incompetent or unethical providers. The current level of
regulation of behavioral health professional is inadequate to provide an
appropriate level of protection to these consumers. Of the over 20,000 licensed
behavioral health providers, the experience and training in the area of behavior
analysis is generally limited to training that has been obtained post degree or
through limited coursework, usually optional, obtained while in school. Specific
training and experience in providing behavioral interventions is not required for
licensure. ( See Attachment 2 for a comparison of the training requirements for
behavioral health professionals and Board Certified Behavior Analysts).
However, behavioral interventions have been identified as best practices for
many issues including depression, ADHD, obsessive compulsive disorders,
autism, and most childrens' behavioral health disorders. Dr. Scott 0. Lilienfeld in
The Scientific Review of Mental Health Practice ( 2004,) notes that many or most
anxiety disorders and most childhood disorders respond better to behavioral and
cognitive behavioral therapies than to supportive therapies or other therapies that
do not rely on behavioral techniques. The lack of expertise in the application of
behavioral interventions among the available licensed professionals, and the
absence of licensure for Board Certified Behavior Analysts to practice or
supervise the clinical practice of services in behavioral health, puts the burden on
consumers to individually determine the competency of potential providers. This
puts an additional duty on consumers of behavioral health services not required
of consumers of other health services presently regulated by the state.
Acknowledging the certification of behavior analysts and including this profession
as a licensable profession would assure access to a wider variety of
professionals.
Establish a code of ethics, and recourse to use amendment to existing
applicable law.
The issue requires resolution via amendment of the applicable licensing laws
either by including the BCBA as a profession regulated by the board of
psychologists or the behavioral health board. The licensed behavior analyst
would be required to meet training, supervision and experience standards as
outlined by the BACB. ( See Attachment 3 for the BACB requirements). Requiring
adherence to these specific standards is one method that insures public safety in
the implementation of the powerful techniques of Applied Behavior Analysis. In
addition, requiring that behavior analysts licensed to practice under the proposed
new law are certified through the BACB would increase protection for the public
by requiring that licensed behavior analysts subscribe to the ethical and
professional guidelines of the BACB.
Board Certified Behavior Analysts are required to abide by a set of practice
guidelines and code of ethics, as are all of the licensed professionals currently
recognized in the state of Arizona. BCBA guidelines are comparable to the
guidelines of other professional organizations, including:
American Anthropological Association
American Educational Research Association
American Psychological Association
American Sociological Association
California Association for Behavior Analysis
Florida Association for Behavior Analysis
National Association of Social Workers
National Association of School Psychologists
Texas Association for Behavior Analysis
These Guidelines address ethical concerns particular to Board Certified Behavior
Analysts and Board Certified Associate Behavior Analysts, as well as concerns
that are salient to the relationship between certified professionals, the people
they serve, and society in general. In addition, the behavior analyst guidelines
include requirements tailored to the unique services and technical interventions
of a behavior analyst.
Specifically, the guidelines establish that a behavior analyst rely on scientific
principles and provide services, teach, and conduct research within the
boundaries of their competence, based on their education, training, supervised
experience, or relevant professional experience. Behavior analysts'
assessments, recommendations, reports, and evaluative statements are based
on information and techniques sufficient to provide appropriate substantiation of
their findings. A behavior analyst must conduct a functional assessment, as
defined in applied behavior analysis best practice literature, to provide the
necessary data to develop an effective behavior change program, and accept as
clients only those individuals or entities ( agencies, firms, etc.) whose behavior
problems, or requested services are commensurate with the behavior analyst's
education, training, and experience. A behavior analyst 1) designs programs that
are based on behavior analytic principles, 2) including assessments of the effects
of other intervention methods, 3) involves the client or the client- surrogate in the
planning of such programs, 4) obtains the consent of the client, and 5) respects
the right of the client to terminate services at any time. The behavior analyst
recommends reinforcement rather than punishment whenever possible. The
behavior analyst minimizes the use of potential reinforcers that may be harmful to
the long- term health of the client ( e. g., cigarettes, or sugar or fat- laden food), or
that may require undesirably marked deprivation procedures as establishing
operations. The behavior analyst collects data, or asks the client, client-surrogate,
or designated others to collect data needed to assess progress within
the program. The behavior analyst modifies the program on the basis of data.
The behavior analyst reviews and appraises the restrictiveness of alternative
interventions and always recommends the least restrictive procedures likely to be
effective in dealing with a behavior problem.
3. Alternatives including regulation of business employers or practitioners
rather than employee practitioners, regulation of the program or service
rather than the individual practitioners, registration of all practitioners and
certification of practitioners, and why the use of alternatives would not be
adequate to protect the public interest, why licensing would serve to
protect the public interest:
Typical employers and extent of autonomy of behavior analysts.
Behavior Analysts provide services to meet diverse behavioral needs. Examples
of these applications include: building the skills and achievements of children in
school settings; enhancing the development, abilities, and choices of children
and adults with different kinds of disabilities; and augmenting the performance
and satisfaction of employees in organizations and businesses. Behavior
Analysts work for both organizations of service providers and in an independent
capacity as consultants or private practitioners.
Because of its prominent applications on behalf of people at- risk and historical
concerns for the humane treatment of consumers, Applied Behavior Analysis has
been the focus of many state regulations. In the course of defining the practice of
behavior analysis and establishing certification for practitioners, some succinct
regulatory definitions of the discipline have been developed in Florida, California
and New York. Massachusetts is currently proposing legislation to license
behavior analysts under the same state law as psychologists. ( See Attachment 4
for the Massachusetts legislation).
The states of Florida, California, New York, Oklahoma, Pennsylvania, and Texas
previously had state certification and credentialing programs for the behavior
analysts, but have transferred all of their credentialing of behavior analysts to the
Behavior Analyst Certification Board.
As is true of other behavioral health professions, the clients of behavior analysts
are diverse socially, economically, culturally and ethnically. Behavior Analysts
help individuals of widely varying functional abilities in a variety of settings
including, predominantly, the settings in which the problem exits. These settings
include private homes, schools, licensed residential settings, private practices,
mental health centers, rehabilitation agencies, private nursing homes, licensed
health facilities, schools and businesses. In Arizona the regulated employers,
such as licensed behavioral health facilities, require licensure for employees
providing behavioral health counseling services, and are unable to recognize the
BCBA as a qualified professional unless helshe holds licensure under the board
of psychology or board of behavioral health. The risk of harm to the public
created by this restriction of practitioners is serious because behavioral health
services are generally provided by individuals one- on- one behind closed doors to
vulnerable patients. In these situations the public relies on the oversight of
supervisors to ensure that practice meets standards. If the supervisor is
unfamiliar with the specific procedures and techniques of behavior analysis,
effective supervision is not possible and the public risk is increased.
Dangers of misuse of techniques by less well trained people or
paraprofessionals under the direction of less well trained professionals.
Problems with the unethical and harmful application of " behavioral - like"
techniques prompted the Florida Legislature in the early 1970' s to form a blue
ribbon panel to study the issue. The recommendations of this blue ribbon panel
resulted in the development of the Florida certification of behavior analysts and
the legislative requirement that individuals developing and applying behavioral
procedures with developmentally delayed individuals become certified. This
process and its inherent protection is recognized as valuable for other
populations and the Board Certified Behavior Analyst has been in demand with
many services for other populations.
Licensed behavioral health professionals and psychologists are uniquely situated
to have an enormous impact on their patients. Appropriately trained and
regulated professionals provide invaluable assistance to help their patients
achieve the highest possible level of functioning and well- being. Untrained or
unregulated individuals, however, have the potential to inflict irreparable harm. If
the system were to provide for behavior analysts the requirements regarding
qualifications for licensure and oversight it could prevent misuse of procedures,
improve fidelity of interventions to the behavioral approach, increase positive
outcomes and reduce cost.
Given the vulnerability of consumers of behavioral health services, it is critical
that they be protected from incompetent or unethical providers. This petition
seeks licensure for Board Certified Behavior Analysts equivalent with behavioral
health professionals or psychologists to ensure that consumers of behavioral
health services receive the same level of protection provided to consumers of
other health care services. Individuals are allowed to practice if they could
demonstrate appropriate levels of education, experience and competence. The
licensing Board is able to provide informed investigations and take action on
complaints against all behavioral health providers.
Efforts made to address the problem.
Voluntary certification of behavior analysts has been instituted to help consumers
identify competent practitioners and to provide them with an avenue of redress
against incompetent or unprofessional practitioners. As previously decided by the
State of Arizona with the Board of Behavioral Health, voluntary certification of
practitioners fails to adequately protect the public. Consumers of behavioral
health services are among the most vulnerable and often the least sophisticated
of the state's residents. It is not reasonable to put the burden on patients to
understand the system and seek out providers and professionals sufficiently
trained and credentialed in behavioral principles and techniques.
The Behavior Analysis Certification Board is a national professional association
that regulates certified practitioners who must adhere to published codes of
ethics, and offers a review process for consumer complaints alleging ethical
violations by practitioners. While admirable, these review processes may be
inadequate to protect the public. First, a professional association offers voluntary
membership to professionals. The association has no authority to review
complaints against non- members. Second, even if a consumer complaint results
in discipline against a member, the association has no power to enforce the
discipline imposed. If a member fails to comply with a disciplinary decision by an
association, the association's only recourse is to eject the member from the
association. Finally, disciplinary reviews by professional associations are
conducted by other professionals in the discipline. The lack of public input into
these reviews compromises the fairness necessary for the public to be assured
that their interests are being adequately protected.
Alternatives considered - regulation of business employers or
practitioners.
The Department of Health Services ( DHS) licenses behavioral health facilities
receiving state funds. DHS requires behavioral health professionals working in
licensed facilities to be licensed or clinically supervised by license holders. A
large percentage of behavioral health practitioners in Arizona, however, do not
have expertise in behavior analysis, and while a Board Certified Behavior Analyst
might work for a licensed behavioral health facility, they may not provide clinical
supervision of others ( wherein the expertise of that professional might be
extended to others practicing for the agency). Currently a BCBA must be
supervised by a licensed professional who may not have gained the knowledge
and expertise to adequately provide the oversight for behavioral services.
Inclusion of the Board Certified Behavior Analyst as a licensed professional in the
State of Arizona would provide for supervision of behaviorally based services by
the appropriately trained professional, and provide the public with the protection
inherent in this system.
4. The benefits to the Public Achieved By Licensing Board Certified
Behavior Analysts include:
The benefits to the public achieved by licensing behavioral health professionals
are increased access to services and increased safety. First, recognition and
inclusion of Board Certified Behavior Analysts in the licensing regulation would
insure that the public would have access to professionals with specialization in
the application of behavioral procedures to promote positive behavior change.
Second, all behavioral health professionals providing behavior analysis services
in Arizona would be subject to the Board's jurisdiction or the jurisdiction of the
Board of Psychology. This oversight function would prevent incompetent and
unprofessional practitioners from providing services outside the scope of any
state regulation and would provide a forum for review of all consumer complaints
against behavioral health professionals. Also of importance, the licensure of
Board Certified Behavior Analysts would allow cost effective behavior analysis
services without redundant supervision from other ( less behaviorally skilled)
licensed behavioral health professionals.
The inclusion of Board Certified Behavior Analysts as licensed professionals
would ensure the public has access to relevant information for making informed
decisions with respect to choosing a professional treatment provider. Currently,
the public is largely unaware that such a specialization exists, or that many
otherwise competent providers of behavioral health do not hold expertise specific
to the application of behavioral procedures.
It is proposed for the licensure of Board Certified Behavior Analysts to be
subsumed under the Board of Behavioral Health or the Board of Psychology. The
designated board would be arranged to include at least one licensed BCBA so
that specific expertise could be represented when making oversight decisions.
The Board's workload and efficiency could be maximized by requiring that
applicants first become certified by the Behavior Analysis Certification Board
( BACB) before applying for licensure with the state of Arizona. The designated
Arizona Board would have the authority to revoke, suspend or not renew licenses
for cause. It would adopt the ethics and practice guidelines established by the
BACB and require adherence to these guidelines. In addition the board would
receive complaints and take disciplinary action against practitioners, and levy the
same fees as other disciplines regulated by the board.
No grandfather clause is proposed or necessary as this does not change or
affect the practice of currently licensed individuals.
It is proposed that the same reciprocity agreements with other jurisdictions are
applied for Board Certified Behavior Analysts who become licensed, as are in
place with other licensed practitioners. The BACB has established training and
supervision guidelines in line with the standards for other licensed behavioral
health providers including Social Work, Psychology and Counseling. Attachment
2 provides detailed information comparing the requirements for Board Certified
Behavior Analysts with other disciplines.
5. The extent to which regulation might harm the public and restrict entry
into the health profession, whether there are similar professions which
should be included or excluded:
The inclusion of Board Certified Behavior Analysts into the current licensure for
Behavioral Health Providers or Psychologists would not restrict access to
qualified providers. Inclusion would expand the available pool of providers to
include these additional, highly trained professionals. The standards proposed
are those currently in place for licensed providers and have not been deemed
unduly restrictive. As the BACB is the national entity governing the recognition
and practice of behavior analysis, the question of recognition and reciprocity of
professionals that migrate from other jurisdiction is simplified. Those BCBAs who
migrate to Arizona would be required to have the same qualifications as the
current Board Certified Behavior Analysts residing in Arizona. The Behavior
Analysis Certification Board certifies a level of behavior analyst below the BCBA
as an associate or assistant behavior analyst. This level requires a bachelor's
degree with specific course work and supervised experience, and minimum score
on a national examination. This level of training and experience corresponds
with the behavior health technician and should not be included in the proposed
legislation.
6. The maintenance of standards including: whether effective quality
assurance standards exist in the health profession and how the proposed
legislation will assure quality:
The existing quality assurance standards for licensed professions ( Behavior
Health Professionals and Psychologists) and the standards of the Behavior
Analysis Certification Board for the BCBA should be combined and applied to the
new category of licensed behavior analyst. The standards for the BCBA would
be strengthened through the inclusion in the licensing regulations. The current
code of ethics for Board Certified Behavior Analysts are practice guidelines, are
not written as enforcement codes, and do not have the strength of law behind
them. Including the BCBA under licensure will allow enforcement of the current
high standards for professional practices already enforced for Behavior Health
Professionals and Psychologists. Standards for suspension and revocation of
licensure that exist for currently licensed professions will be adopted for the new
category of BCBA.
7. A Description of the Groups proposed for regulation:
Currently there are approximately 30 Board Certified Behavior Analysts in the
state. It is estimated that the field will expand as Board Certified Behavior
Analysts are licensed, able to practice independently, and are valuable to
behavioral health service providers as Behavioral Health Professionals. States
that have promoted the recognition of behavior analysts such as Florida,
California and Massachusetts have over 600, over 350 and over 360 Board
Certified Behavior Analysts listed on the Behavior Analyst Certification Board,
respectively. Currently the University of Northern Arizona has a graduate
program to prepare students to become Board Certified Behavior Analysts and
these new practitioners will have an avenue to practice within the Arizona system
rather than migrating to other states that recognize the profession.
Licensure includes those individuals currently certified by the Behavior Analysis
Certification Board. There is no way to determine if non - registered BCBAs
reside in Arizona. Neither is there a way to determine if there are qualified
individuals residing in Arizona who are not certified.
8. Expected cost of regulation:
Both the Behavioral Health Examination Board and the Board of Psychology are
funded through the fees generated by licensing. The national Behavior Analysis
Certification Board is funded through the fees generated by examination and
certification of behavior analysts. It is not anticipated that the expenses will
increase with the addition of this category of professional, as the fees charged to
a BCBA applying for licensure will cover the cost of administering the program. It
is anticipated that the direct impact from licensure on the costs of behavioral
sewices for the state will be a decrease in the cost of services for individuals
sewed by licensed BCBAs. This cost reduction would result from the typical
behavior analytic service structure that provides training and support to the
persons directly involved with the clientlpatient including parents, teachers,
babysitters, etc. As the persons who are most involved with the client are trained
to teach, intervene, and respond using therapeutic techniques there is a
parametrically increased impact of the professional who provides more
therapeutic hours per dollar for the system.
For consumers who would directly pay for behavioral health professionals as
private pay clients, the recognition and regulation of an additional service
specialty may increase access to available services within the current cost
structure as the numbers of licensed behavior analysts and, therefore, licensed
professionals providing services increase. Requiring licensure for individuals
currently practicing without a license would increase their costs and this might be
passed on to the consumers.
Attachment 1
Descriptions of Best Practice Treatment Approaches Utilizing Applied Behavior Analysis
Techniques
There are 26 Best Practices identified by Arizona DBHS. These are:
Assertive Community Treatment *
Multi- systemic Therapy
= Functional Family Therapy
Dialectical Behavior Therapy
= Motivational Interviewing
Cognitive Behavioral Therapy
Supported Employment
= Wrap Around Service
Family Psychoeducation
= Supportive Housing - Therapeutic Foster Care *
= Relapse Prevention* - Family Systems *
= Solution Focused Brief Therapy *
= Community Reinforcement Approach
= Behavioral Marital Therapy
Motivational Enhancement Therapy - Social Skills Training*
= Naltrexone
- Opiate Replacement Therapies Behavior Contracting
Texas Medication Algorithm
Independent Hous~ ngw ith Supports . Brief Intervention for Alcohol AbuselDependence *
Multi- dimensional Family Therapy for Adolescents
= Emot~ onallyF ocused Therapy for Couples
At least 10 ( noted in bold) of these are best practices and are based on, incorporate or rely on
methods of applied behavior analysis. An additional 8 ( noted with an asterisk) often utilize
behav~ orm anagement ( procedures developed from the science of behavior analysis).
Descriptions retrieved 8124107 from the respective websites.
Multisytemic treatment or MST programs include coqnitive behavioral approaches, the behavior
therapies, behavioral parent training, pragmatic family therapies, and certain pharmacological
interventions that have a reasonable evidence base ( U. S. Department of Health and Human
Services [ DHHS], 1999). As these treatments are delivered in a considerably different context
than usual. For example, consistent with the view that the caregiver is key to achieving long- term
outcomes, a MST cognitive behavioral intervention would ideally be delivered by the caregiver
under the consultation of the ( behavior) therapist.
Functional Family Therapy ( FFT) clinicians develop and implement intermediate and, ultimately,
lonn- term behavior change plans that are culturally appropriate, context sensitive. and tailored to
the unique characteristics of each family member. The assessment focus in this phase includes
cognitive ( e. g., attributional processes and coping strategies), interactive ( e. g., reciprocity of
positive rather than negative behaviors, competent parenting, and understanding of behavior
sequences involved in delinquency), and emotional components ( e. g., blaming and negativity).
Clinicians provide concrete behavioral intervention to guide and model specific behavior changes
( e. g., parenting, communication, and conflict management). Particular emphasis is placed on
using Individualized and developmentally appropriate techniques that fit the family relational
system.
Community Reinforcement Approach
The Community Reinforcement Approach ( CRA) is a broad- spectrum behavioral
Proqram for treating substance abuse problems that has been empirically supported within
patients ( Azrin, 1976; Hunt & Azrin, 1973), outpatients ( Azrin, Sisson, Meyers, & Godley, 1982;
Mallams, Godley, Hall, & Meyers, 1982; Meyers & Miller, 2001). and homeless populations
( Smith, Meyers, & Delaney, 1998). In addition, three recent meta- analytic reviews cited it as one
of the most cost- effective alcohol treatment programs currently available ( Finney & Monahan,
1996; Holder, Longbaugh, Miller, & Rubonis, 1991; Miller etal., 1995). The first study to
demonstrate the effectiveness of CRA was conducted more than 25years ago ( Hunt & Azrin,
1973). ( It must be explained that Dr. Azrin is a founding practitioner of Applied Behavior Analysis,
and continues as a prominent leader in the field). References are available in the CRA manual.
Best practice guidelines promulgated by the Division of Health that require the use of
procedures based on Applied Behavior Analysis.
DBHS Best practice guidelines for disorders of attachment:
Through family centered approaches, primary caregivers should be taught how to nurture, how to
understand the reasons for their child's behaviors before disciplinary consequences are
considered, how to interact with children based on emotional, as well as chronological age, how
to be consistent and predictable, how to listen and talk with their children, how to develop and
maintain realistic expectations and how to teach and role model appropriate social behavior.
lnd~ viduatlr eatment of the child must be provided in the least restrictive, effective setting that
sustains proximity to home and natural supports. All service settings, a full array of covered
services, and specialty providers as indicated must be considered. The treatment continuum must
include community- based in- home services, respite, outpatient services and psychotropic
medication prescribing and monitoring. Counseling interventions can include individual, group
and play therapies that promote social skills, anger control, and behavioral channe and
Manaqement. It is understood that the majority of therapeutic interventions used for attachment
disordered children are taken from various therapeutic frameworks such as Psychodynamics,
Gestalt, Cognitive- Behavioral, Family Systems, Ericksonian, Object Relations, Attachment Theory
and Therapy.
DBHS Best practice guidelines for ADHD best practice protocol:
The focus of treatment should be on functional improvement such that the child/ adolescent will be
able to maintain behavior appropriate to hislher developmental level in multiple settings, including
home, school, work or social settings. Environmental Support should be provided to parent( s),
family members, teachers, and other members of the child's community. Each of these
individuals should be active members of the child's service plan. Each team member must have
an understanding of the child's condition, realistic behavioral expectations, and learned and
demonstrated successful behavior techniques, communication and parenting skills. The team
member will use these techniques and skills during and after termination of therapy in managing
ADHD at home, in school and in social situations. The home environment will be modified to
accommodate the clinical needs of the child. A thorough and comprehensive assessment of all
domains of a child's life must be made before a diagnosis is given. The core of the assessment
should be the parental interview, as the diagnosis rests primarily on observations of those closest
to the child and resulting clinical judgment. The child's behavior in home. school, and communitv
settings is evaluated with respect to the features of ADHD, and co- morbid conditions common to
this diagnosis are reviewed. Family functioning and its potential effect on symptoms are reviewed.
Information from the school, regarding the child's behavior and the appropriateness of the
learning environment, is obtained. The use of the Conners Scale or other behavioral rating scales
is particularly helpful in measuring baseline functioning and subsequent improvement.
Therapeutic strategies generally should utilize a broad- based range of interventions that may
include:
OPsycho- Educational approaches
OParent training in behavioral management skills
nclassroorn interventions
OCognitive behavioral therapy
OSocial skills training
Olndividual psychotherapy of the child
OFamily therapy
OLiving skills training
OHealth promotion with a focus on medication education and compliance and health- promoting
activities
OPeer and family support
ORespite
0 Other methods of intervention and treatment to address the specific identified needs of the
child and family.
All services provided should be consistent with the Arizona Principles and should rest, to the
extent possible, on community- based, natural supports, and respect for the child and family's
unique cultucal heritage and needs.
DBHS Best Practice Protocol for Services for individuals with Developmental Disabilities:
( Pertinent to the individuals in the DBHS system with DD)
Individual Counseling:
Cognitive- behavioral strategies may be used, with increased weight on the behavioral
component, for lower functioning individuals. Achievable and relevant goals and objectives
should be identified, and realistic expectations of progress established, as chaining and
generalization of goals may occur slowly.
Behavioral AssessmenVFunctionaI Analysis:
Challenging behaviors, like appropriate behaviors, are maintained by environmental, social and
physical reinforcers. The clinicians' task is to determine the function that the challenging
behaviors play in the individual's daily routine. This task is usually accomplished by conducting a
" Functional Analysis." A functional analysis includes an examination of the following:
flAntecedents and/ or consequences that affect or control a behavior;
OWhether the behavior represents a deficit or an excess, or is situationally appropriate;
UWhether different behavior patterns occur with different situations;
OPossible schedules of reinforcements that maintain the behavior;
OAn examination of environmental aspects and potential physical health issues that may
relate to the challenging behaviors; and
OPotential reinforcers and potential alternative behaviors that may be used in the
treatment plan to strengthen alternative behaviors.
Behaviors must be viewed in the situational and environmental context in which they occur and in
relation to the influences that manifest before, during and afler the behaviors. Antecedents may
provoke behaviors naturally ( like a loud noise causing an individual to jump) or through learning
( recognizing, over time, that self- injurious behavior lead to increased attention). Events following
a behavior can alter the likelihood of it recurring ~ f it is positively or negatively reinforced. Thus,
knowing antecedents and consequent events can be critical to understanding the reasons for
challenging behaviors and to developing therapeutic interventions.
Behavioral assessments must also explore the effects that challenging behaviors have on
caregivers, and who is most challenged by the behaviors. This allows service providers the
opportunity to support and promote the most effective caregiver responses and an opportunity not
only to change behaviors but also to shape and enhance the interpersonal environment in which
they occur.
In order to conduct a functional analysis the clinician will be required to interview family members,
other observers of the behaviors, and the individual as well as directly observe the individual
while helshe is engaged in target behaviors.
The results of the functional analysis lead directly to the formulation of a treatment intervention by
the CFT or ACT. Since interventions will need to occur throughout the day, family members.
teachers or other direct care staff must understand the rationale for the method, the exact
procedures to follow and the documentation that is required to measure the effectiveness of the
interventions.
Behavior Management:
The overall treatment strategy for behavioral interventions should emphasize the teaching of
social, communication and cognitive skills to the individual and effective behavior shaping
techniques to parents, to be used both during and afler termination of therapy. Applied Behavioral
Analysis Techniques and other behavioral management approaches should emphasize:
OThe development and encouragement of constructive and effectwe ways for individuals
to seek the attention they desire.
UPositive reinforcement for appropriate behavior and acknowledgment and reward of
the individual's ability to establish age- appropriate autonomy to the extent possible.
nldentification and minimization of the antecedents to behavioral disruptions, agitation or
self- injury by defining and utilizing positive or negative reinforcers.
OThe enhancement of the individual's repertoire of social and communicative behaviors
through social- pragmatic teaching.
OThe careful documentation in the service plan of desired outcomes and measurable
goals consistent with the individual's behavioral health needs.
Behavioral interventions must be coordinated with other agencies like DDD, which may be
providing similar interventions as part of habilitation. Habilitation services use a variety of
methods designed to maximize the person's abilities. Services typically are offered in the
person's home or community and include activities specific to learning to become more
independent.
Caregivers, family members and other providers in the individual's environment should be
actively engaged, including involvement with " homework" assignments. Strategies must be
integrated with other services and must be based on a thorough familiarity of the individual's
environment, routine, strengths and limitations and the assured cooperation of the individual's
caretakers, guardians, educators and other staff. As for all other service strategies,
signs/ symptoms of relapse or recurrence and exacerbating factors for co- occurring behavioral
health disorders should be identified and strategies developed for coping with exacerbating
factors.
Other governmental agencies promote the use of Applied Behavior Analysis as a best
practice.
The American Association on Mental Retardation, the oldest and largest interdisciplinary
organization of professionals concerned with mental retardation and related disabilities,
designated ABA- based procedures for the treatment of behavioral problems with individuals with
mental retardation and related disorders as " highly recommended" ( their highest rating). Based
on the scientific evidence supporting the efficacy of ABA- based procedures for treating problems
associated with mental retardation and autism, various scientific organizations have concluded
that ABA- based procedures are highly effective, including:
National institute of Mental Health
National Institute of Child Health and Human Development
rhtt- National Academies- Press (" Educating Children with Autism 12001)
Commission on Behavioral And Social Sciences and Education") )
American Association on Mental Retardation) (" Guidelines for the Treatment of
Psychiatric and Behavioral Problems in Mental Retardation"
American Psycholo~ icaAl ssociation ( Division 33; " Guidelines on Effective Behavioral
Treatment for Persons with Mental Retardation and Developmental Disabilities" )
Association for Science in the Treatment of Autism
Surgeon General of the United States 1999 report on mental health stated in reference to the
treatment of autism: " Thirfy years of research demonstrated the efficacy of applied behavioral
methods in reducing inappropriate behavior and in increasing communication, learning, and
appropriate social behavior. "
New York State Department sf Meaith (" Guidelines: Autism/ Pervasive Development
Disorders, Assessment and Intervention for Young Children ( 0- 3), Chapter IV -
Behavioral and Educational Approaches")
Caiifornia State Department of Developmental Services (" Autistic Spectrum
Disorders: Best Practice Guidelines for Screening, Diagnosis and Assessment")
Maine Administrators of Services far Ghifdren with Disabilities (" Report of the
MADSEC Autism Task Force")
-_ r^-- r.-, r *--, ., ..."- -..... -.. r,-. rr--. r-..... l-- ..,.-,. r.. ,. .^. Yt. .. a- _..
Attachment 2 - Requirements of Licenses for Arizona Compared with BCBA Certification Requirements
Licenses and
Certification
Requirements
BCBA
I Specific
( Board
Certified
Behavior
I
Analyst)
Psychologist
Education
Requirement
~ ehavior
Analysis
Training
Master's degree from an
institution of higher
education.
~ e ~ u i r e d
255 class room
Hours of Supervised
Independent
Fieldwork
hours in specific
core content areas
approved by the
Behavior Analyst
Certification Board
1500 hours of Supervised
Independent F~ eldwork~ n
behavlor analysis. The
d~ stnbution of Superwsed
Independent Fieldwork hours
must be at least 10 hours per
week, but not more than 30 hours I per week, for a minimum of 3 1 I I I I
Supervision Hours
25% telephonically, more
ocial Work Education.
~ nd~ v~ dtuhanl group
hours, 10 hours d~ rect
75 total hours and 5%
of total superv~ sed
hours, with at least
biweekly contact,
during
period
supervised work experience theories course
related field from an
accredited institution
including 48 hours in core
Exam
Required
LMFT
Ethics
Training
Required
YES YES
Sunrise application Definition o f Issue, Executive Summary and Question 1
8/ 30/ 2007
Attachment 3- Behavior Analysis Certification Board Requirements
Coursework: College or university courses in behavior analysis, that are taken from
an institution that meets the requirements specified.
The applicant must complete 225 classroom hours of graduate level instruction ( see
Acceptable Coursework below) in the following content areas and for the number of
hours specified :
a. Ethical considerations - 15 hours
b. Definition & characteristics and Principles, processes & concepts - 45 hours
c. Behavioral assessment and Selecting intervention outcomes & strategies - 35
hours
d. Experimental evaluation of interventions - 20 hours
e. Measurement of behavior and Displaying & interpreting behavioral data - 20
hours
f. Behavioral change procedures and Systems support 45 hours
g. Discretionary - 45 hours
Acceptable Coursework: Instruction of the type( s) specified in either a, b, or c,
below, will be accepted toward the coursework requirement.
Amount of Supervised Experience Required:
Supervised Independent Fieldwork: Applicants must complete 1500 hours of Supervised
Independent Fieldwork in behavior analysis. The distribution of Supervised Independent
Fieldwork hours must be at least 10 hours per week, but not more than 30 hours per week, for
a minimum of 3 weeks per month.
Amount of Supervision Required:
Supervised Independent Fieldwork: Applicants must be supervised at least once every 2
weeks for 5% of the total hours they spend in Supervised Independent Fieldwork. Total
supervision must be at least 75 hours. A supervisory period is two weeks.
1 Superv~ sed hours:
I I 5 ' 10
1 O/ O of total hours r_________- I___ I_-_ _ I___---- - - I - --
I
I
I
i Total number of
1 supervised hours 75
! ---.. -
Supervised Independent
Fieldwork
I Frequency of
I i 1 every 2 weeks
supervisor contacts
Total hours requ~ red ' T 1500 -
The applicant's primary focus should be on learning new behavior analytic skills related to the
BACB Third Edition Task List. Activities must adhere to the dimensions of applied behavior
analysis identified by Baer, Wolf, and Risley ( 1968) in the article Some Current Dimensions of
Applied Behavior Analysis published in the Journal of Applied Behavior Analysis. Applicants
are encouraged to have experiences in multiple sites and with multiple supervisors.
I :. . .
I . ,. a I
I i
i
I - Sunrise application Deiinition o f Issue, Executive Summary and Question 1
! - 8/ 30/ 2007
I I
! Appropriate experience activities include:
Conducting assessment activities related to the need for behavioral interventions,
Designing, implementing, and monitoring behavior analysis programs for clients,
Overseeing the implementation of behavior analysis programs by others,
Other activities normally performed by a behavior analyst that are directly related to behavior
analysis such as attending planning meetings regarding the behavior analysis program,
researching the literature related to the program, talking to individuals about the program; plus
any additional activities related to oversight of behavioral programming such as behavior analyst
supervision issues, or evaluation of behavior analysts' performance. The supervisor will determine
if activrties qualify.
Examples of activities that are not appropriate as experience activities include: attending
meetings with little or no behavior analytic content, providing interventions that are not based
in behavior analysis, doing non- behavior analytic administrative activities, or any other
activities that are not directly related to behavior analysis.
A. I n order to provide the public assurance that practitioners will maintain their
competence in the field it is proposed that the standards for continuing
education from the BACB be adopted as well as the requirements for
renewing licensure. The renewal would require proof of continuing education
and a fee. For BCBA recertification in the 3rd year of the certification cycle
requires the following:
1. For BCBA certificants, proof of completion of 36 hours of acceptable
continuing education as described in Section 11.
Type 1
Completion of graduate level college or university courses, for BCBAs, or
undergraduate or graduate, college or university courses, for BCABAs. Course
content must be entirely behavior analytic.
I
1 Type 2
Completion of events sponsored by providers approved by the Behavior Analyst
Certification Board. Any portion or all of the total required number of hours of
continuing education may be applied from this category during any three- year
certification period.
Type 3
Completion of a seminar, colloquium, presentation, conference event, workshop or
symposium not approved by the BACB, only i f they relate directly to the practice of
behavior analysis. A maximum of 25 percent of the total required number of hours of
continuing education may be applied from this category during any three- year
certification period.
TY pe 4
Instruction by the applicant of a category 1 or 2 continuing education events, on a
one- time basis for each event, provided that the applicant was present for the
complete event. A maximum of 25 percent of the total required number of hours of
Sunrise application Definition of Issue, Executive Summary and Question 1
8/ 3 0/ 2007
continuing education may come from this category during any three- year
certification period.
Type 5
Credentialing events or activities initiated and pre- approved for CEU by the BACB. A
maximum of 25 percent of the total required number of hours of continuing
education may come from this category during any three- year certification period.
Type 6
Passing, during the third year of the applicant's certification period, the BACB
certification examination appropriate to the type of certification being renewed.
Sunrise application Definition of Issue, Executive Summary and Question 1
8/ 30/ 2007
Attachment 4 Massachusetts Legislation for Licensure of Behavior
Analysts
H2244, SD2039 - An Act relative to behavior analysts
SECTION 1. Section 1 18 of chapter 1 12 of the General Laws, as appearing in the 2004
Official Edition, is hereby amended by inserting after the word " meanings" in line 3, the
following words:-
" Associate behavior analyst", an individual who by training and experience meets the
requirements of the national Behavior Analyst Certification BoardO and has passed the
examination and received certification as a Board Certified Associate Behavior Analyst 0.
" Behavior analysis", the design, implementation, and evaluation of instructional and
environmental modifications to produce socially significant improvements in human
behavior through skill acquisition and the reduction of problematic behavior. A behavior
analysis program shall be based on empirical research, include the direct observation and
measurement of behavior as well as a functional behavioral assessment; and utilize
antecedent stimuli, positive reinforcement and other consequences to produce behavior
change.
" Behavior analyst", an individual who by training and experience meets the requirements
of the national Behavior Analyst Certification Board O and has passed the examination
and received certification as a Board Certified Behavior Analyst 0 .
SECTION 2. Section 79 of chapter 13 of the General Laws, as appearing in the 2004
Official Edition, is hereby amended by inserting after the word " psychology", in line 10,
the following words:- " or behavior analysis".
SECTION 3. Chapter 112 of the General Laws, as appearing in the 2004 Official Edition,
is hereby amended by inserting after section 119 the following section:-
Section 1 19A. Each person desiring to obtain a license as an associate behavior analyst
shall make application to the board upon such form and in such manner as the board shall
prescribe and shall furnish evidence satisfactory to the board that such person:
( a) is of good moral character;
( b) has passed the examination and received certification as a Board Certified Associate
Behavior AnalystO;
( c) has maintained active status and has fulfilled all requirements for renewal and
recertification as a Board Certified Associate Behavior AnalystO; and
( d) conducts his professional activities in accordance with accepted standards such as the
Ethical Standards of Psychologists of the American Psychological Association and the
Guidelines for Responsible Conduct of the Behavior Analyst Certification BoardO.
Sunrise application Definition of Issue, Executive Summary and Question 1
8/ 30/ 2007
Each person desiring to obtain a license as a behavior analyst shall make application to the
board upon such form and in such manner as the board shall prescribe and shall furnish
evidence satisfactory to the board that such person:
( a) is of good moral character;
( b) has passed the examination and received certification as a Board Certified Behavior
AnalystO;
( c) has maintained active status and has fulfilled all r~ quirementsfo r renewal and
recertification as a Board Certified Associate Behavior Ana1yst. O; and
( d) conducts his professional activities in accordance with accepted standards such as the
Ethical Standards of Psychologists of the American Psychological Association and the
Guidelines for Responsible Conduct of the Behavior Analyst Certification BoardO.
SECTION 4. No person shall hold himself out to be an associate behavior analyst or a
behavior analyst unless he has met the applicable requirements set forth in section one
hundred and eighteen.
Violation of this section shall be punishable by a fine of not more than five hundred
dollars, or by imprisonment for not more than three months, or by the suspension or loss of
a license as a psychologist, or any combination thereof.
SECTION 5. Section 128 of chapter 112 of the General Laws, as appearing in the 2004
Official Edition, is hereby amended by striking out the first paragraph and inserting in
place thereof the following paragraph:-
The board shall investigate all complaints relating to the proper practice of behavior
analysis by any person licensed or certified as a behavior analyst or associate behavior
analyst under sections one hundred and eighteen to one hundred and twenty- nine A,
inclusive.
Sunrise application Definition of Issue, Executive Summary and Question 1
8/ 3 012007
References
Arizona Department of Health Services, ( 2005, April 1). Practice Improvement Protocol 11: Best
Practices. Retrieved August 20, 2007, from ADHS Division of Behavioral Health Services
Web site: http~// www. azdhs qovlbhslquidance/ bp. pdf
BACB. Inc., ( 2007, April). Revised Standards for Board Certified Behavior Analyst@ ( BCBAB).
Retrieved August 20, 2007, from Behavior Analyst Certification Board Web site:
http.// www. bacb. comlbecom frame. html
Baer, Don M., Wolf, Montrose M., & Risley, Todd R. ( 1968). Some Current Dimensions of Applied
Behavior Analysis. Journal of Applied Behavior Analysis, 1, 91 - 97.
Baer, Don M., Wolf, Montrose M., & Risley, Todd R. ( 1987). Some Still Current Dimensions of
Applied Behavior Analysis, Journal of Applied Behavior Analysis, 20, 31 3- 327.
Hagopian, Louis P. & Boelter, Eric W., ( 2005). Applied Behavioral Analysis: Overview and
Summary of Scientific Support. Retrieved August 20. 2007. from Kennedy Krieger Institute
Web site: http: l/ www. kennedvkr1eqer. orq1kki m1sc. isp? pid= 4761
Herbert, James D., Sharp, Ian R., & Gaudiano. Brandon A., ( 2002). Separating fact from fiction in
the etiology and treatment of autism: A scientific review of the evidence. The Scientific
Review of Mental Health Practice, l( 1). Retrieved August 20, 2007, from
http: llsrmhp. orq/ 0lOl lauttsm html
Lovaas, I. Ovar, ( 1981). The ME Book. Austin, TX: Pro- Ed Press.
Meyers, Robert J. & Squires, Daniel D., ( 2001, September). The community reinforcement
approach: A guideline developed for the behavioral health recovery management project.
Retrieved August 20, 2007, from Behaworal Health Recovery Management Web site:
http:// www bhrm orq/ qu~ deltnes/ CRAmanuai. pdf
Multisystemic Therapy Services, ( 1998). Multisystemic Therapy Treatment Model. Retrieved
August 20, 2007, from MST Services Web site:
http: l/ mstservices com/ texVtreatment. html# sum
Rice, Catherine ( 2000). Prevalence of Autism Spectrum Disorders --- Autism and Developmental
Disabilities Monitoring Network, Six Sites, United States, 2000. Retrieved August 20, 2007,
from Centers for Disease Control and Prevention Web site:
http:// cdc qovlmmwrlpreviewlmmwrhtml/ ss560l a1 htm
Satcher, David ( 1 999). Mental Health: A Report of the Surgeon General. A report presented at
the 92nd Annual NAACP Convention, New Orleans, Louisiana. Retrieved August 20, 2007,
from http:/ lwww. cdc. qovlomh/ AMHlfactsheetslmental. htm
Sexton, Thomas L. & Alexander, James F., ( 2000, December). Functional Family Therapy.
Juvenile Justice Bulletin, Retrieved August 20, 2007, from
http: llwww. ncirs. qov/ html/ oiidpliibu12000 12 4/ contents. htmI# acknowledqe
Interim agendas can be obtained via the Internet at http: llwww. azleg. state. az. usllnterimCommittees. asp
ARIZONA STATE SENATE
INTERIM MEETING NOTICE
OPEN TO THE PUBLIC
SENATE HEALTH AND HOUSE HEALTH COMMITTEE OF REFERENCE
Date: Tuesday, November 6, 2007
Time: 9: 30 A. M.
Place: SHR 1
AGENDA
1. Call to Order
2. Opening Remarks
3. Sunset Review of the Board of Homeopathic Medical Examiners
Presentation by Auditor General
Response by Board of Homeopathic Medical Examiners
Public Testimony
Discussion
Recommendations by the Committee of Reference
4. Sunset Review of the Regulatory Board of Physician Assistants
Presentation by Regulatory Board of Physician Assistants
Public Testimony
Discussion
Recommendations by the Committee of Reference
5. Sunset Review of the Board of Behavioral Health Examiners
Presentation by Board of Behavioral Health Examiners
Public Testimony
Discussion
Recommendations by the Committee of Reference
6. Sunset Review of the Acupuncture Board of Examiners
Presentation by Acupuncture Board of Examiners
Public Testimony
Discussion
Recommendations by the Committee of Reference
7. Sunset Review of the Board of Occupational Therapy Examiners
Presentation by Board of Occupational Therapy Examiners
Public Testimony
Discussion
Recommendations by the Committee of Reference
Page 1 of 2
8. Sunrise application of the Arizona Alliance of Non- Physician Surgical Assistants
Presentation by Arizona Alliance of Non- Physician Surgical Assistants
Public Testimony
Discussion
Recommendations by the Committee of Reference
9. Sunrise application of the Southern Arizona Behavioral Health Coalition
Presentation by Southern Arizona Behavioral Health Coalition
Public Testimony
Discussion
Recommendations by the Committee of Reference
10. Sunrise application of the Arizona Dental Association
Presentation by Arizona Dental Association
Public Testimony
Discussion
Recommendations by the Committee of Reference
1 1. Sunrise application of Radiology Practitioner Assistants
Presentation by Radiology Practitioner Assistants
Public Testimony
Discussion
Recommendations by the Committee of Reference
12. Adjourn
Members:
Senator Tom O'Halleran, Co- Chair Representative Bob Stump, Co- Chair
Senator Paula Aboud Representative Nancy Barto
Senator Amanda Aguirre Representative David Bradley
Senator Barbara Leff Representative Linda Lopez
Senator Thayer Verschoor Representative Rick Murphy
Persons with a disability may request a reasonable accommodation such as a sign language interpreter, by contacting the
Senate Secretary's Office: ( 602) 926- 4231 ( voice). Requests should be made as early as possible to allow time to arrange the accommodation
Page 2 of 2
ARIZONA STATE LEGISLATURE
Forty- eighth Legislature - First Regular Session
SENATE HEALTH AND HOUSE HEALTH
COMMITTEE OF REFERENCE
Minutes of Interim Meeting
Tuesday, November 6,2007
Senate Hearing Room 1 - 9: 30 a. m.
Chairman O'Halleran called the meeting to order at 9: 32 a. m. and attendance was noted by the
secretary.
Members Present
Senator l'om O'Halleran, Co- Chair Representative Bob Stump, Co- Chair
Senator Amanda Aguirre Representative Nancy Barto
Senator Barbara Leff Representative David Bradley
Senator Thayer Verschoor Representative Linda Lopez
Representative Rick Murphy
Members Absent
Senator Paula Aboud
Speakers I'resent
Kim I- Iildebrand, Periormance Audit Manager, Office of the Auditor General
Todd Rowe, Board of Homeopathic Medical Examiners
Christine Springer, Board of Homeopathic Medical Examiners
Jerry Weinsheink, representing himself
Marianne Cherney, representing herself
Neil Garfield, Association for Public Access to Medicine
Barney Nugent, representing himself
Linda Heming, CHOICE
Iris Bell, Doctor, Arizona Homeopathic and Integrative Medical Association
Cliff Heinrich, Doctor, representing himself
Kathleen Fry, Doctor, representing herself
Denise Nugent, representing herself
Lee Bakunin, Attorney, representing herself
Bruce Shelton, Doctor, Arizona Homeopathic and Integrative Medical Association
Amanya Jacobs, Director of Evolution of Self School of Homeopathy
Cindy Zukerman, representing herself
Shelly Malone, representing herself
Stan Klusky, representing himself
Gladys Conroy, representing herself
SENATE HEAL1' tl AND HOUSE HEALTH
COMMITTEE OF REFERENCE
November 6,2007
Joan Reynolds, Regulatory Board of Physician Assistants
Debra Rinaudo, Board of Behavioral Health Examiners
Stuart Goodman, Board of Behavioral Health Examincrs
Bev Hermon, BH Consulting
Richard Poppy, Therapeutic Practitioners Alliance of Arizona ( The Alliance)
Rachael Hopkins, representing herself
Ronald Anton, representing himself
Josephine Sbrocca, representing herself
Cedric Davis, Board of Behavioral Health Examiners
Della Estrada, Arizona Acupuncture Board of Examiners
Kathryn Babits, Arizona State Board of Occupational Therapy Examiners
Eugene Smith, Arizona Alliance of Non- Physician Surgical Assistants
Susie Cannata, Arizona Alliance of Non- Physician Surgical Assistants
Rory Hays, Arizona Nurses' Association
Scott Leckie, Radiology Practitioner Assistants
Jane Van Valkenburg, Certification Board for Radiology Practitioner Assistants ( CBRPA)
Mary Connell, M. D., representing herself
Christine Lung, American Society of Radiologic Technologists ( ASRT)
John Gray, Grand Canyon University
Joyce Geyser, Arizona Radiological Society
James Abraham, National Society of Radiology Practitioner Assistants
I- leather Owens, Senate I- lealth Analyst
Aubrey Godwin, Medical Iiadiologic Technology Board of Examiners ( MRTBE)
Teresa Rodgers, Behavioral Health Coalition of Southern Arizona
David Giles, Behavioral Health Coalition of Southern Arizona
Holly Baumann, Southwest Autis~ nR esearch and Resource Center
John MacDonald, Arizona Dental Association ( ADA)
Rick Murray, Arizona Dental Association
Anita Elliott, Arizona Dental Association
Nicole Laslavic, Arizona Statc Dental Hygienists' Association
Janet Midkiff, Arizona State Dental Hygienists' Association
Nicole Albo, Arizona Dental Assistants' Association
Alisa Feugate, Arizona Dental Hygienists' Association
OPENING REMARKS
Chairman O'Halleran welcomcd everyone and requested that the speakers keep their comments
as brief as possible, as the committee members are well- versed in the issues to be discussed
today.
SUNSET REVIEW OF THE BOARD OF HOMEOPAT ~ X A M I N E R S
Presentation by Auditor ~ e n y
~ i m # Performance Audit Manager, Office of the Auditor General, gave a
+ entation on their findings issued in August, 2007 ( Attachment 1). Shc described the history
SENATE HEALTH AND HOUSE HEALTH
COMMITTEE OF REFERENCE
2 November 6,2007
voluntary certification. Chairman O'Halleran stated that this is inde0ed for lic Recommendations by the Committee of Reference
Health Committee of
amend the statutes of the Medical
to allow licensure of Registered
SUNRISE APPLICATION OF THE SOUTHERN ARIZONA BEHAVIORAL HEALTH
COALITION
Presentation by Southern Arizona Behavioral Health Coalition
Teresa Rodgers, Behavioral Health Coalition of Southern Arizona, explained that this application
was submitted in order to ensure that local practitioners meet standards of practice and are
licensed. She explained that behavioral analysts use different methodologies and work with
patients with various diagnoses including developmental disabilities and autism. She stated that
certification began thirty years ago in Florida in mental institutions and has since developed
nationwide.
Dr. Rodgers proposes that licensure go forward as a separate entity using the national standards
of the Behavior Analysis Certification Board.
Representative Lopez asked if there is a training program in Arizona; Dr. Rodgers stated that
Northern Arizona University has a program with 40 students. Representative Lopez asked if
there is a real need for this profession; Dr. Rodgers replied that the profession is growing
nationwide but it is currently difficult to find enough certified behavior analysts to meet the
demand.
Public Testimony
David Giles, Behavioral Health Coalition of Southern Arizona, supports the application,
explaining the importance of treatment plans for cognitively impaired people and the
requirement that treatment plans be authorized by licensed practitioners. He stated that this
profession is the best to treat children with autism.
Senator Leff asked if people practicing now would no longer be able to practice if the Legislature
allows licensure; Mr. Giles replied in the negative, explaining that this would provide a way for
families to find a clinician. Representative Bradley stated that licensure will actually expand
opportunities.
Holly Baumann, Southwest Autism Research and Resource Center, stated her support for this
application, explaining that the current lack of oversight represents a significant healthcare risk
for some of Arizona's most vulnerable citizens.
SENA'I'E HEALTH AND HOUSE HEALTH
COMMITTEE OF REFERENCE
November 6,2007
Discussion
Chairman O'Halleran asked for clarification about the motion; Ms. Owens explained the
interaction with other Boards.
Ms. Renaudo explained that for her agency the concern is the small number of behavioral health
professionals eligible for licensure, and that it would be impossible to regulate it because it will
not be self- funding.
Representative Bradley stated that the number is stagnant because these professionals have no
place to go, and that with licensure people will be drawn to Arizona. Senator Leff stated her
agreement .
Recommendations by the Committee of Reference
Cochairman Stump moved that the Senate and House Health Committee of
Reference approve the sunrise application of the Southern Arizona Behavioral
Health Coalition. The motion carried by a voice vote.
SUNRISE APPLICATION OF THE ARIZONA DENTAL ASSOCIATION /
Presentation by Arizona Dental Association / John MacDonald, Arizona Dental Association ( ADA), to explain the sunrise
application concerning access to care. He issue, including the
community needs assessments that have with stakeholders
( Attachment 14).
Rick Murray, Arizona Dental program proposes the creation of a
position called the Comn~ unity designed to be an extender
of the dental office and to the general supervision of a dentist.
The goal is to help bring across Arizona.
explained that the primary role of a COHR will be as
and oral health promotion and prevention, as
sent to the dental office prior to being seen by
thc dentist. /
the intent is to hire people from within the community, who may then
in the dental profession.
Public estimon + ole Laslavic, Arizona State Dental Hygienists' Association, stated that her organization does
not support the position but will not oppose this sunrise application.
Senator Leff asked for clarification of that position.
SENATE HEALTH AND HOUSE HEALTH
COMMITTEE OF REFERENCE
15 November 6,2007
Janet Midkiff, Arizona State Dental Hygienists' Association, stated that they support the concept
of training community people to be dental health representatives, and that the definition of the
COHR does make sense to them. She stated concerns about the education, licensing, or
certification of the people who fill the COHR positions. She said that her organization would
like to work with the ADA and to be a part of the access to care issue.
Nicole Albo, Arizona Dental Assistants' Association, stated her support for the COHR program
provided that the positions will be filled by certified dental assistants with additional training
components. She stated that she has been working with the ADA to develop a curriculum for
expanded COHR training.
Representative Murphy asked if the committee could approve the concept but not specify the
details, letting the Legislative process do that. Mr. Murray stated that the supervision issue is the
biggest concern.
Alisa Feugate, Arizona Dental Hygienists' Association, stated that she supports the concept of
the COHR but is neutral on the application at this time due to concerns about supervision and
scope of practice.
Recommendations by the Committee of Reference
Cochairman Stump moved that the Senate and House Health Committee of
Reference recommend that the Legislature amend the statutes of the Arizona Board
of Dental Examiners to create a new certified professional, the Community Oral
Health Representative, to coordinate community- based oral health promotion and
provide specified dental care under the general supervision of a licensed dentist.
The motion carried by a voice vote.
Without objection, the meeting adjourned at 4: 15 p. m.
Jane Dooley, Committee Secretary
November 6,2007
( Original minutes, attachments and audio on file in the Office of the Chief Clerk; video archives
available at http:// www. azle~.~ ov/)
SENATE HEALTH AND HOUSE HEALTH
COMMITTEE OF REFERENCE
November 6.2007